OPTOMETRY  LIB, 


H.  A.  STOCKWELL 

OPTOMETRIST 

BERKELEY.  CAUF. 


OPHTHALMIC  SURGERY 


BEARD 


OPHTHALMIC   SURGERY 


A  TREATISE  ON  SURGICAL  OPERATIONS  PERTAINING  TO 

THE  EYE  AND  ITS  APPENDAGES,  WITH  CHAPTERS 

ON    PARA-OPERATIVE     TECHNIC     AND 

MANAGEMENT  OF  INSTRUMENTS 


BY 

CHARLES  H.  BEARD,  M.  D., 

FELLOW    OF  THE    AMERICAN  COLLEGE    OF  SURGEONS;    SURGEON  TO    THE  ILLINOIS    CHARITABLE 

EYE  AND  EAR  INFIRMARY;   OCULIST  TO  THE  PASSAVANT  MEMORIAL   HOSPITAL,    CHICAGO; 

EX-PRESIDENT  OF  THE  CHICAGO    OPHTHALMOLOGICAL  SOCIETY;   MEMBER  OF 

THE  AMERICAN  OPHTHALMOLOGICAL  SOCIETY,   ETC. 


SECOND  EDITION,  REVISED  AND  ENLARGED 


WITH  9  PLATES,  SHOWING  100  INSTRUMENTS 
AND  374  OTHER  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO 

1012   WALNUT   STREET 


OPTOMET 


Copyright,  1914,  by  P.  Blakiston's  Son  &  Co. 


'  II  K  ■    M  A  I'  I.  K  .  !■  H  K  S  S  .  Y  O  U  K  •   I'  A 


OPTOMETRY 
LIBRARY 


PREFACE  TO  THE  SECOND  EDITION. 


The  present  edition  contains  ^^  per  cent,  more  text  and  80  illus- 
trations more  than  did  the  iirst,  yet  the  contents  have  been  so  con- 
densed that  the  size  of  the  book  has  not  been  materially  increased. 
Important  new  matter  has  been  introduced  throughout,  and  two  new 
chapters,  one  on  "The  Newer  Operations  for  Glaucoma,"  the  other 
on  "The  Surgical  Treatment  of  Detachment  of  the  Retina,"  have 
been  written.  Among  the  descriptions  of  valuable  surgical  methods 
that  have  been  inserted  are  those  relative  to  Toti's  and  Butler's 
operations  upon  the  lacrimal  canal,  Elschnig's  and  Motais'  methods 
for  tendon  advancement,  Rogman's  and  Wicherkiewicz's  for  epi- 
canthus,  Angelucci's  for  ptosis,  Verhoeff's  and  Green-Ewing's  for 
entropion,  Terson's  for  ectropion,  Falchi's  for  central  coloboma  of  the 
upper  lid;  Buedinger's  restoration  of  the  lower  lid,  using  cartilage  of 
the  ear,  and  Meisner's  restoration  of  the  entire  lid,  using  the  whole 
thickness  of  the  helix;  a  large  section,  embodying  the  Schobel- 
Kuhnt  methods  of  conjunctivo-keratoplasty,  has  been  added;  like- 
wise, the  newer  measures  for  keratoconus  and  those  for  corneal 
grafting,  and  the  improved  technic  for  anterior  syncchiotomy. 
In  the  chapter  on  Extraction  of  Cataract  the  new  features  include 
Elschnig's  simple  extraction  with  peripheral  incision  of  the  iris, 
Homer  Smith's  preliminary  capsulotomy,  Hulen's  vacuum  extrac- 
tion of  the  lens  in  its  capsule,  and  the  latest  phase  of  the  "Indian 
Operation."     The  alphabetical  index  has  been  elaborated. 

The  author  is  most  grateful  for  the  many  flattering  comments 
upon  the  former  edition  that  he  has  received  from  the  medical 
profession  and  press  both  in  his  own  country  and  abroad. 


M758S65 


PREFACE  TO  THE  FIRST  EDITION 


The  selection  of  the  matters  discussed  in  the  following  pages 
and  the  manner  of  treating  them  are  the  results  of  the  careful 
study  and  practical  application  of  the  involved  principles  made  in 
hospitals,  dispensaries,  and  in  private  practice,  extending  over  a 
period  of  twenty-six  years.  They  began  while  the  author  was  a 
student  under  Agnew  and  Knapp,  in  1883,  were  later  continued 
in  England  and  on  the  Continent  of  Europe,  and  have  ever  since 
been  diligently  prosecuted. 

There  has  been  no  separate  work  on  the  surgery  of  the  eye 
published  in  the  United  States  for  nearly  half  a  century,  and  but 
little  written  upon  the  subject  in  connection  with  the  more  general 
treatises  on  ophthalmology,  if  we  except  the  admirable  contribu- 
tion of  Knapp  to  the  System  of  Norris  and  Oliver  some  twelve 
years  ago.  The  object  here  has  been  to  supply  a  work  that  would 
embody  not  only  what  experience  has  taught  and  judgment 
prompted  as  being  the  more  valued  measures  of  all  countries,  but, 
in  particular,  those  of  our  own  country. 

The  presentation  of  portions  devoted  to  the  history  of  the  dif- 
ferent procedures  is  deemed  of  great  importance,  but  to  keep 
them  from  appearing  obtrusive  they  have  been  made  as  concise 
as  practicable. 

The  classification  followed  has  seemed  the  logical  one  to  adopt. 
The  chapter  on  the  extraction  of  foreign  bodies  from  the  interior 
of  the  eye  has  been  placed  in  a  class  of  its  own  instead  of  with 
the  operations  upon  the  globe.  In  the  author's  opinion,  the 
handling  of  foreign  bodies  in  the  eye  is  a  subject  apart,  the 
methods  employed  in  their  diagnosis,  localization,  and  extraction 

vii 


VIU  PREFACE 

involving  so  much  that  is  not  in  line  with  other  branches  of 
ophthalmic  surgery. 

In  viev^r  of  the  fact  that  the  illustrations  have  been  chiefly  the 
fruits  of  his  individual  labor,  the  writer  begs  his  confreres  not  to 
consider  them  in  the  hght  of  mere  pictures  or  from  the  stand- 
point of  artists,  but  as  conceptions  of  how  these  things  should 
appear  by  one  with  considerable  experience  in  the  matters  de- 
picted and  with  a  little  facility  in  the  power  of  delineation. 

In  closing,  the  author  offers  his  sincere  thanks  to  all  others  who 

have  been  instrumental  in  supplying  whatever  of  merit  this  volume 

contains. 

Charles  H.  Beard. 

Chicago. 


LIST  OF  CONTENTS. 


CHAPTER   I. 

PAGE 

Para-operative  Technic i 

The  preparation  of  surgeons,  assistants,  patient,  instruments, 
and  dressings.  Sterilization,  anesthesia,  blood-letting;  in 
short,  all  appliances,  applications,  and  methods  employed 
in  connection  with  ophthalmic  operations  and  with  their 
after-treatment. 

CHAPTER  II. 

Instruments  and  their  Management 53 

The  approved  qualities  and  forms  of  the  instruments  used 
in  ophthalmic  surgery,  and  what  features  are  commendable 
and  what  objectionable  in  them,  with  reasons  and  explana- 
tions. Minute  descriptions  of  models,  and,  in  conclusion, 
the  manipulation  or  handling,  and  the  care  or  maintenance 
of  eye  instruments. 

CHAPTER  III. 

Operations  upon  the  Appendages  of  the  Eye.     The  Lacrimal 

Apparatus 120 

The  surgical  treatment  of  affections  of  the  lacrimal  canal, 
together  with  detailed  descriptions  of  the  principal  oper- 
ations performed  upon  the  entire  lacrimal  apparatus,  both 
secretory  and  drainage. 

CHAPTER   IV. 

The  Appendages  Continued.     Operations    upon    the   External 

Muscles  of  the  Eye 158 

The  different  kinds  of  squint  and  a  history  of  the  surgery  of 
the  defect.  The  technic  of  the  leading  measures  for  its 
correction,  including  tenotomy,  advancement,  shortening  and 
lengthening  of  tendons  and  check  ligaments,  and  the  acci- 
dents and  complications  that  may  occur.  Critical  consider- 
ations of  methods  of  advancement. 

CHAPTER  V. 

The  Appendages  Continued.      Operations  upon  the  Lids.     .    .    .     207 
Eversion,  epilation,    and    electrolysis    of    cilia,    methods    for 
chalazion,  canthoplasty,  tarsorrhaphy,  and  epicanthus. 

CHAPTER  VI. 

The  Appendages  Continued.     Operations  for  Ptosis 230 

Kinds  of  ptosis,  history  of  the  surgical  measures  devised  for 
it,  with  the  principles  underlying  them.  Descriptions  of  the 
technic  evolved  in  the  leading  methods  for  righting  the  fallen 
lid,  and  an  extended  summary  dealing  with  the  different 
procedures  and  their  relative  values. 

ix 


X  LIST    OF    CONTENTS 

CHAPTER  VII. 

PAGE 

The      Appendages      Continued.      Operations      for      Entropion, 

Ectropion  and  Blepharoplasty 253 

Operations  for  spastic  entropion,  cicatricial  entropion  and 
trichiasis,  with  the  history  and  evolution  of  such  surgery. 
Ectropion,  its  varieties,  such  as  spastic,  mechanical,  mucous, 
atonic,  and  cicatricial.  Blepharoplasty  in  all  its  phases,  as.by 
sliding  and  pedunculated  flaps,  by  dermic  and  epidermic 
grafts,  etc.,  with  exhaustive  detail  of  technic  under  each  of 
the  several  headings. 


CHAPTER  VIII. 

The  Appendages  Continued.  Operations  upon  the  Conjunctiva.  329 
The  surgery  of  partial  and  total  symblepharon,  and_  the 
restoration  of  the  conjunctival  cul-de-sacs.  Pterygium, 
true,  false,  and  recurrent,  and  appropriate  surgical  measures 
for  the  different  kinds,  including  excision,  transplantation, 
ligation,  cauterization,  and  skin  grafting.  Peritomy  and 
peridectomy. 

CHAPTER  IX. 

The     Appendages     Continued.     The     Surgical     Treatment     of 

Trachoma ■     3^3 

Historical.  The  classification  of  methods  mto  mechanical, 
chemical,  and  operative.  Details  of  technic  relative  to  each 
class,  as  scraping,  massage,  expression,  cauterization, 
radiation,  and  excision.  The  last  comprises  all  forms  of 
excision,  whether  of  conjunctiva  alone  or  of  that  membrane 
combined  with  excision  of  the  tarsus. 


CHAPTER  X. 

Operations  upon  the  Globe 379 

These  relate  first  to  the  outer  walls  of  the  globe— comprised 
by  cornea  and  sclera.  Measures  for  foreign  bodies  in  the 
cornea,  corneal  cautery,  paracentesis,  massage,  keratoplasty, 
anterior  staphyloma,  conical  cornea  and  tattooage.  The 
scleral  surgery  includes  sclerotomy,  anterior  and  posterior, 
cyclodialysis,  trephining,  amputations,  exenteration,  enuclea- 
tion, and  the  substitution  of  a  prothesis  in  the  globe  or  in 
Tenon's  capsule.  Operations  upon  the  iris.  Iridotomy, 
irito-dialysis,  irito-ectomy,  synechiotomy,  and  iridectomy  in 
all  its  forms  and  phases. 


CHAPTER  XI. 

Operations  upon  the  Globe  Continued.  Extraction  ofCat.vract.  497 
Preparation  of  the  patient  and  of  the  eye.  Description  of 
approved  technic  for  the  various  forms  of  extraction.  Ex- 
tended commentary  on  the  accidents  and  complications 
incident  to  extraction,  their  causes  and  their  remedies. 
Discission  of  primary  and  secondary  cataract,  couching  or 
depression,  and  suction.  Extraction  of  the  lens  in  its 
capsule.  The  history  of  extraction  and  its  instrumentation, 
with  concluding  dissertation  on  the  modern  corneal  section. 


LIST    OF    CONTENTS  XI 

C  A  AFTER  XII. 


PAGE 


The  Newer  Operations  for  Glaucoma 623 

How  the  different  measures  seek  to  accomplish  their  purpose. 
Simple  anterior  sclerotomy.  Pression  massage,  or  malax- 
ation  after  anterior  sclerotomy.  Objections  to  extensive 
scleral  openings.  Combined  anterior  sclerotomy.  The  ob- 
ject of  the  iridectomy.  Sclerotomy  of  Herbert,  of  Bjerrum, 
of  Wicherkeiwicz  and  of  Beard.  Van  Lint's  T-shaped  sclerot- 
om^^  Sclerectomy.  Perforating  sclerectomy  of  Lagrange  and 
of  Holth.  Trephination  of  the  sclera.  Trephination — Elliot's. 
Different  forms  of  trephine.  Beard's  instrument  and  method. 
Formation  of  the  conjunctival  flap  for  trephination.  Non- 
perforating  sclerectomy  of  Bettremieux,  and  the  theory  as  to 
its  mode  of  action.  Fistulous  tracts  by  means  of  silk  thread. 
Review  of  the  different  methods. 

CHAPTER  XIII. 

Operations  for  Detachment  of  the  Retina 660 

Nature  and  varieties  of  detachment.  Classification  of  the 
surgical  measures  devised  for  its  cure,  and  how  they  seek  to 
accomplish  their  end.  Simple  scleral  puncture.  Thermo- 
or  galvano-cautery.  Bull's  discission  of  restraining  bands. 
Elschnig's  modification  of  Mueller's  procedure.  Deutsch- 
mann's  operations,  Bettremieux's  nonperforating  sclerec- 
tomy in  detachment.  Subconjunctival  injections.  Why 
antiglaucomatous  operations  tend  to  cure  detachment.  Sta- 
tistics as  to  surgical  and  nonsurgical  measures.  Reasons  for 
making  careful  and  repeated  ophthalmoscopic  examinations. 

CHAPTER  XIV. 

Operations  upon  the  Orbit 670 

The  surgery  of  foreign  bodies  in  the  orbit.  Kronlein's 
operation  and  its  modifications.  The  removal  of  tumors. 
Incisions  of  the  orbit  evacuant  and  diagnostic.  Exenter- 
ation, partial  and  total. 

CHAPTER  XV. 

The  Removal  of  Foreign  Bodies  from  the  Interior  of  the  Eye.  .   687 
Their  abstraction  from  the  anterior  chamber;  from  the  iris; 
from   the   posterior   chamber;   from   the    vitreous    chamber. 
Their    localization    in    the    eye    and    in    the    orbit.      Magnet 
operations  and  their  technic. 


CHAPTER  XVI. 


Alphabetical  Index. 


729 


OPHTHALMIC  SURGERY. 


CHAPTER  I. 
PARA-OPERATIVE  TECHNIC. 

Asepsis. — Under  favorable  conditions  all  incised  wounds  tend 
to  heal  per  primam  intentionem,  and,  as  remarked  by  Snellen,  this 
is  especially  true  of  wounds  of  the  eye.  If  they  are  allowed  proper 
coaptation  and  left  undisturbed,  the  only  bar  to  primary  union  is 
some  form  of  infection.  Under  thorough  asepsis,  then,  nature  can 
be  confidently  relied  upon.  Yet,  when  we  consider  the  status  of 
our  knowledge  relative  to  the  value  and  the  means  of  asepsis,  how 
often  are  we  reproached  by  our  operative  results!  Notwithstanding 
the  degree  of  perfection  we  have  reached  in  the  science  and  the  art 
of  surgery  the  advantage  is  still  on  the  side  of  the  operator  who  is 
most  thorough  and  consistent  in  carrying  out  antiseptic  precautions, 
rather  than  on  the  side  of  mere  skill.  What  has  been  aptly  termed 
an  "antiseptic  conscience"  is  a  necessary  attribute  of  every  one  in 
any  way  concerned.  To  this  must  be  added  an  aseptic  conscious- 
ness and  subconsciousness,  as  well.  For,  unless  we  accjuire  actual 
habits  of  surgical  cleanliness,  and  try  to  impart  them  to  all  those 
around  us,  the  most  elaborate  and  up-to-date  preparations  are 
being  forever  rendered  futile  by  some  little  inadvertence,  like  soiling 
a  finger  or  an  instrument  by  contact  with  an  uncleansed  object. 

The  key-note  to  asepsis  is  sterilization.  This  is  of  two  kinds, 
relative  and  absolute.  The  first  refers  to  the  preparation  of  the 
hands  and  persons  of  surgeons,  attendants,  patients,  and  of  the 
parts  concerned  in  the  proposed  surgical  measure.  The  second 
is  applicable  only  to  inanimate  objects,  such  as  instruments,  articles 
used  in  making  applications,  the  materials  for  dressings,  etc. 
Obviously  vital  animal  tissue  cannot  be  subjected  to  this  form  of 
sterilization  Therefore,  in  the  use  of  purifying  solutions  upon  it, 
one  is  inclined  to  make  up  in  abundance  what  is  lacking  in  strength. 

Preparation  of  the  Hands  and  Forearms.— It  is  well  to  include 
the  hands  and  arms  of  the  patient  as  well  as  those  of  the  o])crator 

I 


2  PARA-OPERATIVE    TECHNIC 

and  all  of  his  aids  in  this  process.  They  arc  first  scrubbed  with 
good  soap,  liquid  or  solid,  and  tepid  water,  by  means  of  a  brush 
that  is  not  too  stiff.  The  nails  are  trimmed,  cleaned  and  scrubbed 
with  the  brush.  The  hands  are  then  rinsed  with  pure  warm  water, 
using  the  brush.  After  drying  on  a  sterile  towel,  they  may  now  be 
anointed  with  a  mixture  of  alcohol,  glycerin,  and  one  of  the  highly 
antiseptic  essential  oils,  as  that  of  cloves  or  of  cinnamon,  to  be 
immediately  followed  by  a  good  rubbing.  This  has  the  property 
of  great  penetration,  entering  into  the  ducts  of  the  sweat  and 
sebaceous  glands,  and  permeating  the  deeper  layers  of  epithelial 
masses.  Lastly,  they  are  washed  lightly  in  sterile  water  and  wiped 
perfectly  dry  on  a  sterile  towel.  Allowing  the  hands  to  dry  spon- 
taneously is  not  so  cleanly,  as  the  moisture  catches  dust.  The  oft- 
repeated  washing  of  the  hands  with  solutions  of  irritating  antisep- 
tics like  sublimate,  formalin,  and  carbolic  acid  has  the  effect  of 
making  them  sore,  and  rough  with  dead  epidermis,  without  in  the 
least  rendering  them  less  infectious.  A  soap  impregnated  with  a 
grinding  material  is  excellent  for  hands  that  are  inclined  to  be  rough. 

Gloves. — The  more  important  and  exacting  operations  upon 
the  eye  are  performed  without  the  surgeon's  fingers  ever  coming  in 
contact  with  the  field  of  operation.  Hence,  the  wearing  of  rubber 
gloves  on  his  part  would  be  not  only  uncalled  for,  but  when  the  ex- 
treme exactness  of  most  ophthalmic  surgery  is  considered,  positively 
unadvised.  For  all  of  his  assistants,  however,  to  wear  them,  were 
both  prudent  and  desirable.  Especially  is  this  true  as  regards  those 
who  make  and  handle  the  cotton  sponges,  or  thread,  or  any  object 
that  actually  touches  the  site  of  operation. 

Sterilization  of  Instruments. — There  are  three  methods  more 
or  less  in  use  for  this  purpose,  that  by  dry  heat,  that  by  moist  heat, 
and  that  by  strong  antiseptics.  It  need  hardly  be  said  that  this 
proceeding  takes  ])lace  immediately  before  the  operation.  When 
prepared  by  dry  heat  tlic  instruments  arc  put  into  some  form  of 
stove  or  oven,  of  which  there  are  many  efficient  kinds  on  the  market. 
Here  they  are  ex})osed  for  twenty  minutes,  or  longer,  to  a  temperature 
of  300°  V.  This  is  ;i])])licablc  to  all  kinds  of  instruments,  even  to 
those  with  ixory  handles.  In  winter,  or  in  \crv  moist  weather, 
the  door  of  the  o\fn  is  icfl  o\)vn  for  a  few  moments  after  the  heat 
is  started,  in  order  to  ])revent  the  (juick  corrosion  of  fine  edges  and 
points  that  comes  from  condensation.  Sterilizing  in  a  llame  is 
fatal  to  anv  instrument. 


STERILIZATIOX    BY    MOIST    HEAT  3 

By  Moist  Heat. — It  is  customary  to  put  in  this  class  sterilization 
by  means  of  live  steam,  in  an  autoclave,  under  })ressurc.  In  rcalitv, 
if  carried  out  to  the  letter,  this  is  a  form  of  dry  sterilization.  In  this 
country  eye  instruments  are  rarely  subjected  to  this  process.  The 
method  most  in  vogue  and  most  to  be  recommended  is  by  boiling. 
Contrary  to  many  adverse  statements  and  comments,  I  believe 
this  method  the  best  for  all  kinds  of  eye  instruments.  That  is, 
just  as  appropriate  as  any  for  the  finer  cutting  implements.  True 
the  instruments  must  be  manufactured  with  a  view  to  being  so 
treated.  They  must  have  metal  handles — be  all  of  metal,  in  fact, 
and  the  procedure  must  be  conducted  by  one  who  knows  and 
does  full  duty  in  the  matter.  The  metal  of  the  vessel  used  for  the 
boiling  should  not  be  capable  of  entering  into  any  chemical  action 
with  the  contained  solution  that  would  be  deleterious  to  the  instru- 
ments. I  cannot  do  better  than  give  a  description  of  it  as  practised 
in  the  Illinois  Eye  and  Ear  Infirmary.  All  the  more  delicate  in- 
struments are  placed  in  a  metal  rack,  provided  with  a  handle  and 
with  a  clamp  which  holds  them  securely,  the  points  and  edges  of 
the  sharp  ones  having  been  previously  tested  on  the  trial-kid.  The 
rack  projects  beyond  the  extremities  of  the  instruments  so  that  they 
cannot  be  jammed  against  the  boiler.  There  is  a  separate  com- 
partment in  the  boiler  for  this  rack.  The  coarser  and  non-cutting 
articles  are  dropped  carefully  into  another  compartment.  The 
boiler  contains  a  solution  of  sodium  hydrate,  or  borax,  one  to  two 
parts  per  thousand.  The  presence  of  the  salt  serves  to  elevate 
the  degree  of  ebullition  and  to  restrain  oxidation.  The  solution 
is  perfect — ^i.e.,  there  must  be  none  of  the  salt  undissolved.  The 
instruments  are  not  put  in  until  the  water  reaches  the  boiling- 
point.  Of  course  the  boiling  ceases  the  moment  they  are  immersed. 
One  waits,  then,  until  it  begins  again  before  starting  to  time  the 
sterilization.  The  time  should  not  be  less  than  ten  minutes. 
Fifteen  w^ould  not  be  too  long.  The  instruments  are  then  lifted  out 
drained,  and  laid  on  sterile  towels  on  the  trays  of  the  serving  tables. 
It  would  be  well  to  have  a  small  oven  in  which  to  dry  them  quickly 
just  before  using.  The  plan,  so  generally  followed,  of  putting  them 
fresh  from  the  boiler  into  some  liquid,  there  to  remain  till  used,  is 
not  consstent  with  good  surgery.  It  is  not  pleasant  to  either  operator 
or  operated  to  have  water  dropping  into  the  eye  from  the  instru- 
ments; besides,  since  the  sterilization  of  the  hands  is  only  relative, 
infection  could,  in  this  way,  be  carried  from  the  fingers  into  the 


4  PARA-OPERATIVE    TECHNIC 

wounds.  If  i)romptly  dried  the  moment  they  are  removed  from 
the  sterilizer  one  need  have  no  apprehension  as  to  the  points  and 
edges  of  the  fmest  knives.  If  left  in  the  air,  covered  with  moisture, 
oxidation  becomes  at  once  very  active,  and  it  is  precisely  the  thin 
edges  and  sharp  points  that  will  suffer  most.  All  sutures  are  boiled 
ready  threaded  in  their  needles.  If  to  be  treated  with  paraffin, 
or  other  waxy  material,  this  is  best  put  on  afterward,  as  the  consider- 
able handling  necessitated  by  the  threading  is  apt  to  contaminate 
the  suture. 

Reeve,  of  Toronto,  boils  his  cutting  instruments  in  oil,  to  avoid 
corrosion. 

By  Strong  Antiseptics. — ^This  is  the  least  sure  and  satisfactory 
method,  and  must  ever  be  one  of  expediency,  not  of  choice.  It 
consists  in  letting  the  instruments  lie  for  15  minutes  or  longer  in  a 
bath  of  one  of  several  liquids.  The  commoner  are  40%  formalin, 
95%  phenol,  95%  alcohol,  and  pure  chloroform.  They  are  then 
taken  out  and  washed  in  sterile  water.  This  is  an  uncertain  proc- 
ess, for  if  there  be  the  thinnest  possible  film  of  any  fatty  or  albu- 
minous substance  on  the  instrument  it  acts  as  a  barrier  to  disinfec- 
tion. Moreover,  all  these  fluids  attack  the  steel  with  some  degree 
of  activity.  This  form  of  sterilization  is  made  much  surer  by  wiping 
the  instruments  repeatedly,  and  hard,  with  sterile,  soft  linen  just 
before  putting  them  into  the  bath.  If  done  intelligently,  this  also 
enhances  the  polish  and  the  keenness  of  the  trenchant  articles  wiped. 
It  is  not  a  bad  idea  to  have  the  cloth  wet  with  the  antiseptic.  It 
was  the  practice  of  Agnew,  of  New  York,  to  wipe  his  Graefe  knife 
long  and  hard  with  soft  linen,  before  the  days  of  antisepsis,  to 
render  it  cleaner,  brighter  and  sharper. 

Preparation  of  the  Patient. — This  is  divided  into  general  and 
local.  General  preparation  is  of  two  kinds,  physical  and  mental. 
General  preparation  may  be  begun  at  an  indehnite  time  previous 
to  the  operation,  and  should  never,  in  case  of  major  operations,  be 
started  less  than  24  hours  previously.  First,  on  entering  the  hospi- 
tal come  the  taking  of  the  histories,  family,  ])ersonal,  and  clinical, 
then  the  physical  examinations,  general  and  local.  These  include 
urinalysis,  inquiry  inlo  llie  state  of  circulatory  and  vascular  systems 
(if  subject  is  not  young),  nose,  tliroat,  lungs,  heart,  digestion,  etc. 
The  bowels  are  emptied  by  l)r()ken  doses  of  calomel  followed  by 
citrate  of  magnesia  or  salts,  or  by  castor  oil.  Tlie  diet  is  li([uid 
or  verv  light,      if  the  operation  is  to  be  under  narcosis,  or  if  the 


PREPARATION    OF    THE    PATIENT  5 

subject  is  nervous  or  apprehensive,  it  is  well  to  give  a  small  dose 
of  morphin,  or  chloretone,  or  bromid  of  sodium,   forty  to  sixty 
minutes  before  the  start  for  the  surgical  room.     The  patient  is 
questioned  as  to  cough,  and,  if  general  anesthesia  is  contemplated, 
as  to  behavior  in  any  former  narcosis.     Both  eyes  and  their  ap- 
pendages arc  thoroughly  examined  and  the  results  recorded.     Partic- 
ular care  is  directed  to  the  condition  of  the  pupils,  the  fundi,  the 
cornea,    the   conjunctiva   and   the   lacrimal   canals.     Bacteriologic 
investigation  of  even  the  healthy  appearing  conjunctiva  is  of  positive 
advantage  in  that  an  incipient  pathogenic  or  pyogenic  infection 
may  be  discovered  and  disaster  averted  by  a  postponement  of  the 
proposed  operation.     The  vision,  the   refraction,  fields,  etc.,   are 
noted.     The  subject  must  be  made  as  clean  as  possible,  but  it  is 
best  to  leave  it  to  the  discretion  of  a  trained   attendant  whether 
or  not  regular  tub  bathing  and  shampooing  be  resorted  to.     Along 
with   all  this  goes  the  mental  or  psychologic  preparation.     The 
beauties  and  advantages  of  hospital  life  and  treatment  are  extolled 
and  instructions  given  as  to  how  best  to  profit  by  them,  how  friendly 
everyone  is  to  everyone  else,  etc.     Incidentally  the  patient  is  put 
through  a  system  of  training  in  the  matter  of  turning  the  eyes  in 
various  directions,  opening  and  closing  them  without  undue  effort, 
and  of  having  them  touched  and  handled.     Unless  there  is  some 
positive  indication,  no  local  preparation  is  inaugurated  prior  to 
one  hour,  or  even  30  minutes,  before  the  operation.     The  use  of 
antiseptics  in  the  conjunctival  sac  and  of  bandages  for  a  day  or 
two  beforehand  is  omitted  as  worse  than  useless.     ]\Iuch  of  this 
subject  is  given  in  the  chapter  on  Extraction,     Suffice  it  to  state 
here  that,  by  way  of  local  preparation,  the  eyelids  and  surrounding 
areas  are  scrubbed  with  sterile  soap  and  warm  water,  followed  by 
rinsing  with  warm  sublimate  solution  1-2,000,  the  subject  mean- 
while keeping  the  eyes  tightly  shut.     The  supercilia  are  not  shaved 
unless  extra  heavy.     The  cilia  are  washed,  and  the  lids  manipulated 
to  empty  the  Meibomian  and  other  ducts  along  the  free  borders. 
The  cilia  before  extractions  and  iridectomies  are  coated  by  wiping 
them  with   cotton  wet  with   benzin,  and,  lastly,  the  conjunctival 
sac  is  copiously  douched  with  warm  boric  acid  solution.     A  light 
boric  acid  dressing  is  then  put  on  the  eye  and  fixed  by  a  simple 
muslin  strip  tied  on  diagonally,  to  be  left  till  the  time  for  the  opera- 
tion arrives.     The  hair  of    women  is    neatly  combed    back  and 
braided.     The  nails  arc  manicured  and  the  hands  are  scrubbed. 


6  PARA-OPERATIVE    TECHNIC 

The  patient  is  taken  to  the  operating  room  in  night  clothing,  i.e., 
all  ready  for  bed.  The  eye  is  copiously  tlooded  with  warm  boric 
or  salt  solution  before,  during,  and  after  the  operation.  One  at- 
tempts by  this  liberal  use  of  a  mild  antiseptic  to  make  up,  as  it  were, 
for  one's  inability  to  employ  a  strong  one. 

Sterilization  of  all  dressings,  such  as  bandages,  cotton,  gauze, 
and  of  gowns,  caps,  masks,  inhalers,  etc.,  is  done  by  means  of  the 
large  steam  autoclaves.  Usually  the  various  articles  are  done  up 
in  stout  cotton  bags,  which  are  securely  tied.  They  are  not  removed 
either  from  the  sterilizer  or  from  the  bags  until  needed.  All  ap- 
pliances, applications,  implements,  and  drugs,  of  whatever  descrip- 
tion, used  before,  during,  or  after  the  operation,  are  sterilized  by 
either  dry  or  moist  heat. 

Everyone  who  has  a  duty  to  perform  in  connection  with  an  opera- 
tion is  clad  in  a  sterile  gown  and  in  a  cap  to  cover  the  hair.  Nurses 
and  aids  wear  gloves,  while  the  surgeon  and  his  immediate  assistant 
have  mouths  and  beards  covered  by  masks. 

Surgeon's  Operating  Masks. — "The  principal  object  of  these 
convenient  ap])liances  is  to  protect  the  operative  field  against  in- 
fection from  the  expiratory  efforts  of  the  operator  and  assistants 


Sr^.. 


/    h 


lM<;.   r.      Mikuli. 


Kic.  2. — Mikulicz  mask. 


in  talking,  coughing,  sneezing,  etc.  They  supersede  the  use,  for 
the  same  purpose,  of  plain  pieces  of  gauze  tied  over  the  lower  part 
of  the  face  around  to  the  back  of  the  head.  By  the  laller  method, 
however,  asitle  from  its  being  a  far  less  convenient  one  than  the 
other,  to  say  nothing  of  the  discomfort  to  the  wearer,  there  was 
always  more  or  less  danger  of  having  the  operator's  hands  con- 


OPERATING    MASKS  7 

taminated  by  coming  in  contact  with  the  hair  while  in  the  act  of 
tying  the  gauze  at  the  back  of  the  head.  This  and  other  objections 
to  wearing  some  sort  of  shield  have  been  done  away  with  by  such 
wire  masks  as  we  illustrate;  these  may  be  easily  attached  to  the  head 
in  a  manner  similar  to  spectacles,  requiring  only  the  handling  of 
the  mask  itself,  which  should  be  previously  sterilized.  Wilson, 
of  Bridgeport,  has  attachments  on  the  mounting  of  his  operating 
spectacles  for  holding  the  gauze  mask. 

"One  of  the  two  best-known  patterns  of  these  wire  masks  is  that 
of  Mikulicz,   which  consists  of  a   wire   framework   so   made   that 


Fig.  3.— Tuttle's  mask. 


Fig. 


-Tulll 


when  covered  with  two  thicknesses  of  gauze  stitched  to  all  sides, 
it  effectually  co\crs  the  nose  and  mouth  of  the  wearer  when  it  is 
placed  in  position.  It  is  instantly  adjusted  to  the  head,  and  when 
not  in  use  a  number  of  them  may  be  nested  and  temple  bars  folded 
over,  so  as  to  take  up  a  minimum  amount  of  room. 

"The  other  pattern  now  being  rapidly  adopted  by  many  leading 
surgeons  and  hospitals,  as  fulfilling  the  purpose  admirably,  is  known 
as  Tuttle's  mask.  This  is  a  modification,  by  Dr.  Edward  C. 
Tuttle,  of  a  somewhat  similar  contrivance  used  in  some  European 
hospitals;  and  while  they  are  also  made  of  wire,  they  are  different  in 
construction  from  those  first  described,  as  will  be  seen  by  comparing 
the  illustrations  shown  herewith.  On  these  frames  the  gauze  is 
to  be  attached  only  to  the  upper  part,  but  for  the  entire  length  of 
same,  back  to  the  very  ends  of  the  temi)le  bars,  so  as  to  allow  the 
gauze,  after  the  mask  has  been  put  on,  to  hang  down  lO  to  18  inches 


8  PARA-OPERATIVE    TECHNIC 

over  the  front  and  sides  of  the  head,  covering  also  the  ears;  the 
lower  part  of  the  gauze  is  then  placed  underneath  the  operating 
gown  before  the  latter  is  buttoned  up,  affording  protection  in  every 
needed  way.  It  will  be  seen  that  the  bottom  part  of  the  frame 
stands  out  from  the  lower  part  of  the  wearer's  face  in  such  a  position 
as  to  hold  the  gauze  away  from  it,  thereby  insuring  comfort. 

"Of  the  two  kinds  of  masks  herein  described,  the  first  mentioned 
has  the  advantage  of  being  instantly  adjusted  to  the  head,  whereas 
the  other,  even  though  it  may  take  a  trifle  longer  to  put  on,  is  pre- 
ferred by  many  on  account  of  its  giving  the  desired  protection  in  a 
more  complete  way.  It  is  well  to  note  that  where  an  operating 
cap  is  worn  with  a  Tuttle's  Mask,  only  the  eyes  and  their  immediate 
vicinity  are  left  exposed,  while  the  remaining  portions  of  more  than 
the  entire  front  half  of  head  and  neck  are  completely  covered. 
Furthermore,  it  should  be  remembered  that  both  types  mentioned 
are  so  constructed  as  not  to  allow  the  gauze  to  rest  against  the 
face  of  wearer,  thereby  enabling  him  to  feel  at  perfect  ease,  which 
is  not  the  case  where  gauze  alone  is  worn;  also  that  the  wire  temple 
bars  may  be  easily  bent,  so  that  the  masks  can  be  readily  adjusted 
to  fit  almost  anyone." 

The  Operating  Room. — The  best  sort  of  operating  room,  de- 
scribed in  a  general  way,  is  one  that  is  dry,  commodious,  that  is  well 
ventilated  without  opening  windows  or  doors,  easily  heated  in 
winter,  and  that  has  an  abundance  of  light.  Particularly  desirable 
is  a  broad  north  window.  This  insures  a  uniform  light  without 
interference  by  direct  sunlight.  If  this  window  be  set  at  an  angle 
of  30°  to  45°,  inclining  inward,  it  is  preferable  to  a  perpendicular 
window.  Operations  wherein  corneal  reflections  can  be  a  disturb- 
ing factor  are  made  easier  by  a  window  thus  inclined.  With  the 
patient  lying  on  the  table,  feet  toward  the  vertical  window,  as  is  the 
favorite  position,  unless  the  table  be  so  far  removed  from  the  window 
as  to  greatly  reduce  the  illumination,  the  image  of  the  window  lies 
inconveniently  high  up  on  the  cornea.  Now,  if  the  window  were 
tilted  toward  the  table,  just  in  ])ro])ortion  as  the  slant  of  the  window 
would  increase  up  to  45°,  just  in  the  same  degree  would  the  reflex  be 
lowered.  This  is  illustrated  by  the  accompanying  drawings. 
A  and  B  represent  the  left  e\'e  of  a  subject  lying  on  a  table  with 
feet  toward  the  window.  .1  shows  the  image  of  a  vertical  window 
and  B  that  of  one  inclined  inward  about  40°,  the  distance  of  the 
table  from  the  window  being  the  same  in  both  instances.     Next 


ANESTHESIA  9 

in  choice  to  the  inclined  window  as  a  source  of  light  is  the  \crlical, 
though  to  get  the  best  illumination  the  table  would  be  placed 
diagonally,  with  the  foot  near  the  window.  A  sky-light  is  not 
satisfactory.  Perhaps  the  best  all-around  light  is  the  artificial, 
for  by  the  use  of  portable  electric  photosphores,  or  other  electric 
hand-lamps,  and  large  biconvex  lenses,  one  can  get  whatever 
intensity  is  desirable,  and  can  cause  the  reflexes  to  fall  wherever 
they  are  least  in  the  way.  Fixed  lights,  or  those  adjustable  kinds 
supported  by  their  own  stands,  are  much  less  convenient.  They  are 
in  the  way,  require  a  fresh  adjustment  for  each  change  of  position 
or  movement  of  the  patient,  and  the  surgeon  may,  at  a  critical 
moment,  find  that  his  hand  casts  a  shadow  upon  the  operative  field. 
In  the  hands  of  an  assistant  of  the  right  sort  the  hand  lamp  can  be 


Fig. 


■A,  Reflex  near  vertical  window.      B,  Reflex  near  inclined  window. 


made  to  fulfill  every  requirement.  Walls,  ceilings,  floor,  woodwork 
and  furniture  of  the  room  are  all  white  and  of  materials,  or  covered 
with  materials,  that  most  readily  admit  of  washing,  fumigating, 
or  vigorous  disinfection  generally,  ^^'indow  shades  are  of  a  material 
easily  cleaned,  and  work  from  below  by  heavy  gilt  (metallic)  picture 
cord,  so  as  to  raise  the  least  amount  of  dust  in  being  put  up  or  down. 
No  pus  cases  and  no  re-dressings  are  allowed  in  the  clean  operating 
room. 

Anesthesia.— Instead  of  the  classification  "  local ' '  and  "  general," 
it  would  be  simpler  and  better  English  to  distinguish  these  two  con- 
ditions by  the  terms  anesthesia,  meaning  the  loss  of  sensation  in  any 
particular  part  of  the  body  due  to  the  contact  of  the  sensory  nerves 
supplying  that  part  with  a  drug  that  causes  temporary  paralysis, 
and  narcosis,  meaning  that  condition  of  general  stupor  and  uncon- 
sciousness, resembling  sleep,  caused  by  the  wide  diffusion  of  the 
poisonous  drug  in  the  circulation.  Thanks  to  local  anesthetics  the 
eye-surgeon  is  now  enabled  to  dispense  with  narcosis  for  the  vast 


lO  PARA-OPERATIVE    TECHNIC 

majority  of  operations.  Indeed,  there  is  no  surgical  measure 
resorted  to  by  the  oculist  for  which  narcosis  is  not,  now  and  then, 
omitted. 

Local. — Local  anesthesia  is  produced,  in  eye  surgery,  in  several 
ways;  as  by  the  instillation  of  solutions  of  anesthetics  into  the  con- 
junctival sac — applicable  to  operations  upon  the  mucous  membrane 
or  upon  the  globe.  Instillation  of  the  same  solutions  into  open 
surgical  wounds — applicable  to  operations  upon  the  globe  or  its 
appendages,  and  by  the  infiltration  method  of  Oberst,  or  the  com- 
bined infiltration  and  cocain  method  of  Schleich;  the  last  two  being 
applicable  only  to  operations  upon  the  appendages.  Another  form 
of  local  anesthesia  proper  to  mention  is  that  by  freezing  with  the 
spray  of  anesthyl  or  plain  chlorid  of  ethyl  or  other  highly  volatile 
substance.  This  serves  well  for  the  incision  of  abscesses  of  the  lids 
or  orbit,  especially  in  children  or  excessively  sensitive  adults.  Of 
course,  the  eyeball  must  be  protected  from  the  cold.  So  far 
ophthalmic  surgeons  have  had  little  or  nothing  to  do  with  the 
intraneural  method  of  Gushing,  and  nothing  with  the  spinal 
anesthesia  of  Corning  and  Bier. 

Of  all  the  local  anesthetics  cocain,  after  twenty-five  years  of 
trial,  still  retains  its  supremacy.  Its  maximum  of  efficiency  can 
be  obtained  with  solutions  varying  in  strength  from  2  to  4%. 
Stronger  solutions  only  serve  to  increase  the  objectionable  qualities 
of  the  drug.  Holocain  stands  next  in  popularity.  It  is  effective 
in  solution  of  only  1%,  and  has  the  advantage  of  retaining  its  proper- 
ties longer  than  cocain.  The  chief  objections  to  cocain  arise  from 
overdosage  or  prolonged  application.  This  leads  to  dryness  and 
desquamation  of  the  corneal  epithelium,  to  dilation  or  relaxation 
of  the  blood-vessels,  and  to  hypotonicity  of  the  globe.  The  first 
favors  infection,  and  the  last  two  cause  hemorrhage.  The  third 
objection  is  turned  to  a  virtue,  however,  in  glaucoma,  where  cocain, 
notwithstanding  its  mydriatic  efi'ect,  may  be  used  with  impunity 
not  only  as  an  anesthetic,  but  also  as  a  remedy.  The  first  effects 
of  cocain  on  the  normal  eye  are  contraction  of  the  blood-vessels 
and  perfect  anesthesia.  Hence,  it  is  most  ex])edicnt  to  o])erate 
during  the  ])rimary  stage  in  so  far  as  il  is  possible.  To  this  end  the 
instillations  should  not  be  begun  longer  than  ten  minutes  before  the 
operation.  A  good  rule  is  to  start  tlii'  boiling  of  the  instruments 
and  the  application  of  the  cocain  simultaneously.  Four  drops  with 
two-minute  intervals  is  sufficient.     Jf  the  eye  be  hyperemic  it  is  less 


INFILTRATION    ANESTHF.SIA  II 

susceptible  to  the  drug,  but  it  can  be  blanched  by  adrenalin,  and 
then  anesthetized.  A  convenient  and  highly  efficacious  form  of 
cocain  application  is  the  fresh  sterile  cocain  ointment.  This  has 
such  staying  qualities  that  a  single  laying-on  is  enough.  More- 
over, it  is  said  not  to  disturb  the  corneal  epithelium  when  fat  instead 
of  water  is  the  vehicle.  Ramsay  recommends  a  few  drops  of  5% 
chlorctonc  solution,  along  with  the  cocain,  to  offset  the  harmful 
results  to  the  epithelium.  It  has  been  often  denied  that  there  is 
aught  accomplished  by  dropping  cocain  into  the  open  wound  in 
operations  upon  the  appendages,  but  the  facts  do  not  seem  to  up- 
hold the  denial. 

Infiltration  Anesthesia. — It  had  long  been  known  that  a  dense 
inhltration,  of  the  skin,  for  instance,  caused  anesthesia  of  the  part. 
Oberst,  in  1889,  turned  this  to  account  by  producing  artificial 
infiltration,  by  means  of  a  hypodermic  syringe  and  distilled  or 
salt  water  preparatory  to  the  making  of  incisions.  Schleich,  in 
1889,  went  further,  and  added  a  modicum  of  cocain  (1/8  to  1/4%) 
to  the  fluid  for  the  syringe.  Both  these  methods  are  rather  exten- 
sively employed  in  the  surgery  of  the  lids.  A  wheal,  or  a  series  of 
wheals,  of  edema  is  raised  at  the  site  of  the  proposed  operation  by 
introducing  a  fine  hypodermic  needle  nearly  its  whole  length 
into  the  skin,  and  gradually  withdrawing  it  as  the  liquid  is  injected. 
To  be  free  from  danger,  if  the  Schleich  method  is  used,  either  the 
cocain  should  be  in  very  minute  quantity  or  else  the  ring  of  a 
clamp  should  be  thrown  around  the  wheal  to  prevent  the  solution 
from  entering  the  general  circulation.  The  anesthesia  is  absolute, 
but  the  changed  aspect  of  the  tissues,  and  the  swelling,  are  against 
the  procedure,  as  is  also  the  greater  post-operative  reaction  which 
ensues.  A  good  formula  for  the  solution  is  that  of  Guttman, 
of  New  York,  to  wit:  Natr.  chlorid  0.2,  cocain  hydrobrom.  0.05, 
aqua  destill.,  100. 

Narcosis. — It  would  seem  that  tliere  are  always  to  be  a  certain 
number  of  operations,  such  as  iridectomies  for  acute  glaucoma, 
enucleations,  extensive  plastic  measures,  not  to  s])eak  of  those  upon 
the  timid  and  the  very  young,  etc.,  that  must  be  done  under  narcosis. 
How  choose  a  narcotic?  This  is  a  matter-that  is  largely  a  question 
of  natural  selection.  That  is  to  say,  it  is  decided  mainly  by  the 
conditions — the  age  and  physical  state  of  the  patient,  the  character 
of  the  operation,  etc.  My  preference  would  be  for  ether,  preceded 
by  nitrous  oxid,  all  things  being  equal,  but  I  would  not  give  ether 


12  PARA-OPERATIVE    TECHNIC 

to  persons  of  advanced  age  with  diseased  lungs  or  kidneys  or  to 
those  with  bronchitis.  For  these,  provided  the  operation  were  of 
short  duration,  I  would  choose  nitrous  oxid  followed  by  ethyl 
chlorid— or  even  the  latter  alone— or  either  alone.  Chloroform 
is  the  nicest  of  all  narcotics,  but  the  dangers— one  death  in  a  little 
over  three  thousand — to  my  mind,  more  than  counterbalance  its 
advantages.  Nitrous  oxid  is  the  safest,  but  it  is  impracticable 
for  any  but  the  briefest  operations.  Ether  is  practically  as  safe- 
one  death  in  15,000.  The  risks  with  ether  are  almost  nil  and  those 
of  chloroform  are  greatly  lessened  if  they  are  given  properly  warmed, 
and  after  the  most  approved  methods.  A  tyro  ought  never  to  be 
entrusted  with  the  narcosis,  and  constant  watchfulness  is  necessary 
on  the  part  of  the  most  skilled  anesthetist.  It  is  important  that  the 
psychic  state  of  the  subjects  be  favorable.  To  this  end  they  are 
encouraged  and  cheered  in  every  possible  way.  In  addition  to 
these  suggestive  measures  those  who  seem  to  be  tilled  with  dread  or 
fright  are  given  a  dose  of  some  calming  drug — 1/6  to  1/4  gr.  of 
morphin,  5  to  10  grains  of  chloretone,  or  30  gr.  of  bromid  of  soda, 
45  minutes  to  one  hour  before  taking  the  anesthetic.  The  more 
composed  the  patient  the  more  quiet  the  first  stages  of  the  narcosis, 
and  the  freer  the  post-narcotic  period  from  nausea  and  shock.  The 
practice  of  bringing  the  patient  into  the  operating  room  in  a  perfectly 
conscious  state,  there  to  be  confronted  by  surgeons  and  attendants, 
all  gowned,  and  by  a  great  array  of  paraphernalia-  suggestive  of 
blood,  completely  demoralizes  certain  timid  subjects  and  is  much  to 
be  deprecated.  The  narcosis  should  be  produced  either  in  the 
private  room  or  in  a  special  anesthesia  chamber.  Above  all, 
perhaps,  is  the  importance  of  making  the  period  of  narcosis  as  brief 
as  possible.  In  general  surgery  it  is  not  so  much  the  operation  that 
counts  for  fatal  results  as  it  is  deep  and  prolonged  narcosis. 

During  any  operation  on  the  eye,  the  mucus  which  so  frequently 
accumulates  in  the  mouth  and  throat  during  the  administration  of 
ether,  is  most  objectionable,  as  it  necessitates  stopping  the  operation 
for  its  removal  and  endangers  the  field.  This  excessive  secretion 
may  be  most  effectually  prevented  by  the  hypodermic  administra- 
tion of  atropin  sulphate  gr.  1/200  to  1/150,  combined  with  morphin 
suli)hate  gr.  1/16  to  1/8,  about  one  hour  before  the  operation. 

Inhalers. — As  to  inhalers  the  simplest  apj^aralus  is  usually 
the  best.  The  drop  method  on  a  simple,  gauze  covered  wire 
inhaler  for  ether  and  chloroform  is  about  as  good  as  any.     I  prefer 


DRESSINGS  13 

Jordan's  inhaler  for  eye  operations  as  there  is  a  notch  for  the 
nose  at  the  top,  and  the  handle  projects  over  the  chin,  thus  putting 
the  hand  that  holds  it  out  of  the  way.  Where  this  is  not  at  hand, 
the  cone  of  towel  and  i)aper  with  absorbent  cotton  to  hold  the  liquid, 
for  ether,  or  a  simple  towel  or  napkin  for  chloroform,  will  answer 
the  purpose.  The  subject  is  first  made  to  breathe  with  the  inhaler 
in  place,  but  uncharged  with  the  anesthetic.  The  latter  is  then 
gradually  added.  Screaming  children  may  have  a  deep  cone,  i.e., 
with  plenty  of  air  space,  saturated  with  ether  clapped  on  at  once, 
trusting  partly  to  asphyxia  to  produce  sleep.  Along  with  the 
tanks  of  nitrous  oxid  there  is  always  one  of  oxygen,  and  hypodermic 
syringes  are  provided,  ready  loaded  with  strychnia,  brandy,  or  other 
stimulants,  nor  is  there  wanting  the  means  for  making  infusion  of 
salt  solution.  All  these  things  to  be  used  in  an  emergency  must 
he  prepared  and  on  the  spot.  The  patient  is  carefully  watched  for  an 
hour  or  two  immediately  after  the  narcosis  for  the  double  purpose 
of  noting  his  physical  condition  and  of  preventing  injury  to  the  eye 
or  derangement  of  the  dressing  by  some  unconscious  act. 

Dressings. — ^The  materials  that  compose  modern  eye-dressings 
are  not  of  great  variety  or  overnumerous,  but  their  forms  and 
modes  of  application,  at  the  hands  of  the  different  individuals,  are 
diverse  as  well  as  interesting.  Relatively  few  seem  to  be  so  precise 
and  exacting  as  a  matter  of  such  prime  importance  demands.  If 
the  surgeon  himself  is  negligent  and  slovenly  in  this  respect  what 
can  be  expected  of  other  attendants  like  internes  and  nurses  ? 

Gauze. — This  fabric  does  not  enter  so  largely  into  the  needs  of 
the  opthalmic  surgeons  as  into  the  requirements  of  those  who  practise 
other  branches  of  the  art.  It  comes  in  sealed  packages,  supposedly 
ready  for  use,  but  it  is  well  to  sterilize  it  again  if  means  are  at  hand 
for  doing  so.  For  the  most  part  plain  gauze — not  impregnated 
with  any  drug — is  employed.  This  should  be  of  soft  texture  and 
highly  absorbent.  Borated  gauze  is  interchangeable  with  the  plain 
and  stands  sterilization  perfectly.  Certain  of  the  impregnated 
gauzes,  however,  as  the  moist  ones,  lose  their  properties  by  the 
process  and  must  be  used  directly  from  the  can.  Iodoform  gauze  is 
useful  chiefly  as  a  packing,  e.g.,  in  the  form  of  tents  for  abscess 
cavities.  Bichlorid  gauze  is  apt  to  be  irritating,  especially  to  the 
skin  of  many  patients. 

Cotton. — The  quality  of  absorbent  cotton  as  found  on  sale  is 
an  uncertain   thing  unless  one  knows  and  can  obtain   i)articular 


14 


PARA-OPERATIVE    TECHNIC 


brands.  The  best  cotton  is  white,  clean,  of  long  fibre,  and  is 
instantly  absorbent.  It  comes  neatly  laminated,  and  with  the 
great  bulk  of  the  fibres  running  lengthwise  of  the  bolt  or  roll.  A 
distinctive  feature  is  its  feel.  It  is  clingy  to  the  touch,  and  when 
rubbed  between  the  fingers  the  fibers  show  great  friction.  Poor 
cotton  is  not  white,  not  clean,  is  shoddy,  or  of  short  fibre,  is  irregularly 
laminated,  and,  because  of  the  oil  remaining  in  it,  does  not  readily 
absorb  liquids.  To  the  touch  it  has  a  silky  feel,  and  when  rubbed 
between  the  fingers  is  slippery.  Absorbent  cotton  is  used  either 
plain  or  borated.  It  cannot  be  trusted  without  being  freshly  steril- 
ized. The  roll  of  cotton  is  not  made  into  pieces  of  appropriate 
size  by  cutting,  but  by  pulling.  When  cut,  the  edges  are  too  thick 
and  abrupt. 

Bandages.— These  are  made  of  white  flannel,  gauze,  muslin, 
or  netting,  cut  into  strips  of  suitable  width  and  length.  For  a 
pressure  bandage  flannel  is  probably  the  most  fitting  fabric,  because 
of  its  elasticity.  This  same  quality  makes  it  objectionable  for 
general  use;  besides,  it  is  rather  warm  for  summer.  Muslin,  ex- 
cept it  be  of  the  sleaziest,  is  too  stiff  and  unyielding.  Gauze  makes 
a  fine  bandage,  but  to  be  good  it  is  expensive.  The  material  that 
seems  most  nearly  to  fulfill  all  requirements  is  a  good  quality  of 
white  mosquito  netting.  This  was  first  employed  for  eye  bandages 
at  the  Illinois  Eye  and  Ear  Infirmary  26  years  ago.  Its  use  has 
now  become  almost  universal  in  this  country.  The  choicest  kind 
is  quite  white,  is  well  covered  with  sizing,  has  a  moderately  small 
mesh,  is  free  from  bars  of  heavier  weaving,  and  costs,  now,  about 
80  cents  per  bolt.  The  bolts  each  contain  a  single  piece  eight 
yards  long  and  two  yards  wide.  The  length  is  just  right  for  one 
double  or  for  two  single  bandages.  It  is  so  folded  that  by  opening 
the  bolt  very  slightly  one  has  a  strip  1/2  yard  by  2  yards,  containing 
sixteen  thicknesses.  By  pinning  this  to  a  cloth  on  a  table,  it  can 
be  cut  with  heavy  shears— or  pinned  to  a  regular  cutting  table, 
can  be  more  accurately  divided  with  a  strong,  sharp  knife.  Thus, 
a  cut  of  18  inches  will  make  a  strip  8  yards  long.  The  strips  are 
exactly  three  and  one-half  inches  wide  They  are  nicely  rolled, 
and  the  end  fastened  with  a  pin.  The  goods  must  be  folded 
straight,  and  the  cutting  done  with  exactness,  else  the  bandage  will 
be  on  the  bias  and  ravel  badly.  This  bandage  is  applied  wet- 
soaking  wet.  With  a  little  practice  it  can  be  put  on  quite  smoothly. 
It  conforms  to  the  head  and,  when  dry,  has  staying  qualities  that 


EANDAGINC.  1 5 

are  truly  remarkable.  The  netting  1)an(la<i;e  is  ne\  er  used  a  second 
time.  In  order  to  remove  it  from  the  head  it  is  cut  with  stron<^, 
blunt-pointed  scissors  just  above  the  unoperated  eye,  or  at  the 
temple.  Starch  bandages  are  rarely  used  in  eye  practice.  There 
are  two  forms  of  bandage,  the  simple  strip,  or  tie  (Fig.  6),  and 
the  roller,  or  full  length.  The  last  may  be  either  double  or  single. 
For  the  adult  bandage  the  width  is  three  inches — strip  or  roller; 
for  children,  somewhat  narrower.  The  netting  bandage  is  made 
wider  because,  being  applied  wet,  it  stretches  and  grows  narrower. 
The  length  of  the  simple  tie  is  about  one  yard,  or  meter;  that  of 
the  roller,  four  yards.  The  double  eye  bandage  is,  of  course,  8 
yards  long. 

Bandaging. — This  is  an  art  that  few  acquire  to  a  high  degree. 
Before  applying  the  bandage  a  proper  pad  of  cotton  must  be  built 
up  over  the  closed  lids.  Dry  cotton  must  never  come  in  contact  with 
the  bare  lids,  either  in  bandaging  or  wiping  an  eye,  as  the  loose  fibres 
get  into  the  palpebral  fissure  and  irritate.  This  does  not  happen 
with  wet  cotton.  A  thin,  gauze-like  layer  of  cotton  is  lifted  from  a 
piece,  it  is  fashioned  into  a  rough  square,  measuring  about  two 
inches  each  way,  dropped  into  a  pan  of  boric  acid  solution,  taken 
up  dripping  wet  and  applied  to  the  gently  closed  lids,  with  the 
fibres  running  vertically — i.e.,  athwart  the  palpebral  fissure.  Thus, 
each  fibre  helps  to  hold  the  lids  together.  This  veil-like  piece  of 
cotton  is  smoothed  down — squeegeed,  as  it  were— on  the  skin,  by 
gentle  touches  with  the  bulbs  of  the  finger  or  with  a  cotton  sponge. 
On  this  is  built,  in  a  number  of  successive  layers,  a  generous  pad  of 
dry  cotton,  being  careful  to  fill  in,  first,  the  deeper  depression  around 
the  globe.  The  pad  is  not  built  straight  out,  i.e.— perpendicular 
to  the  plane  of  the  front  face — ^but  inclined  toward  the  temple,  for 
the  reason  that  the  first  turn  of  the  bandage,  coming  as  it  does, 
from  beneath  the  ear  on  that  side,  would,  in  the  first  instance,  pull 
the  pile  of  cotton  over  onto  nose  and  forehead.  It  is  highly  im- 
prudent and  bungling  to  dab  the  whole  quantity  of  dry  cotton  on  in 
one  big  wad.  The  greatest  pressure  is  thus  brought  to  bear  upon 
the  cornea  alone,  instead  of  being  evenly  distributed  oxer  thr  lids 
and  globe  as  when  the  pad  is  properly  built  on.  If  it  is  to  be  a  tie 
bandage,  the  strip  of  netting  is  laid,  near  its  middle,  onto  the  pad  of 
cotton,  and  diagonally,  one  end  passing  beneath  the  ear  on  the  same 
side,  and  the  other  up  over  the  forehead  on  the  opposite  side,  then 
the  ends  are  brought  together  and  snuglv  tied  a  little  to  one  side  of 


i6 


PARA-OPERATIVE    TECHNIC 


the  top  of  the  head.  If  netting  is  used  it  is  put  on  dry  (see  Fig.  6). 
If  both  eyes  are  to  be  bandaged,  another  strip  is  put  on  in  the  same 
way,  or  a  single  strip  may  be  put  straight  around  the  head,  and  tied 
at  the  side — not  over  the  occiput.  Needless  to  state,  tie  bandages 
are  not  expected  to  remain  on  for  long  intervals. 

Another  of  the  Infirmary  specialties  in  dressings  is  that  shown  in 
Fig.  7.  It  is,  to  begin  with,  the  netting  strip  tied  on  as  in 
F\<^.   6,   though    extra    smooth     and     tight.      Now.    it   is    painted 


Fig.  6.— Ncllin^  sti 


uf  collodion  bandan;c. 


over  on  forehead  and  cheek  with  a  thick  coating  of  flexible  collodion. 
As  soon  as  the  collodion  dries,  the  bandage  is  untied  and  the  ends 
cut  off  as  shown  in  Fig.  7.  This  makes  an  excellent  dressing, 
particularly  for  hot  weather,  or  for  children  at  any  season,  and  for 
all  ambulant  cases.  It  serves  well  for  women,  also,  who  then  have 
an  opportunity  of  arranging  their  hair,  which  is  always  a  source 
of  worrv  to  llicm  wlien  the  entire  head  is  swathed. 


MONOCULAR   ROLLER 


17 


The    Single    or   Monocular    Roller.— (Fig.    8.)     The   colion 

pad  is  put  on  precisely  as  for  the  tie  bandage  described.  The 
four-yard  netting  bandage,  well  soaived  in  boric  acid  solution,  is 
lightly  squeezed  to  prevent  dripping.  The  end  is  started  on  the 
forehead  just  above  the  eye  to  be  bandaged  and  passing  thence 
over  the  other  eye.     In  the  figure  it  is  the  right  eve.     The  bandage 


Fig.  7.  -('..llcliMni/cc!  ncllinj^  hanchi.ur. 

iS  given  one  snug  turn  straight  around  the  head  and  in  such  a  way 
that  the  highest  point  of  the  occijMtal  prominence  is  in  the  center 
of  the  strip.  This  prevents  slipping  cither  up  or  down  (see 
Fig.  9).  The  strip  is  carried  on  around,  inclining  downward  at 
the  left  side  of  the  head,  but  always  keeping  well  above  the  left 
eye.  It  passes  just  above  the  left  ear,  then  across  the  base  of  the 
occiput,  then  close  up  beneath  the  right  ear,  thence  diagonally 
upward  over  the  center  of  the  pad  of  cotton,  thence  almost  vertically 
across  the  forehead,  as  if  it  were  going  over  the  top  of  the  head. 


i8 


PARA-OPERATIVE    TECHNIC 


Now  it  is  reversed,  carried  downward  and  Ixickward  around  again, 
passed  again  over  the  pad  of  cotton,  this  time  with  its  edge  against 
the  nose — up  and  reversed  as  before,  carried  a  third  time  around 
and  up.  This,  the  last  turn  that  hes  on  the  cotton  pad,  is  carried 
more  toward  the  right  temple,  so  that  now  the  entire  pad  is  covered. 


S.— MoncHula: 


It  is  again  taken  upward  and  rcxcrscd,  1)ul,  'nslead  of  passing 
downward  at  the  back,  wlial  remains  of  ihc  banckige  is  passed 
straight  around  the  head,  as  was  llie  first  turn.  The  end  is  fixed 
with  two  ordinary  pins-  -nol  with  safely  pins,  'i'he  edge  of  bandage 
and  frazzles  of  cotton  at  the  side  of  the  nose  arc  lucked  under  with 
closed  scissors   blades.     The  bandage  is  not  carried   low  enough 


BINOCULAR    KOI.I.KR 


19 


at  the  back  lo  rcsl  upon  ihc  neck,  lOr  ilir  inov (.'iiirnts  of  the  head 
would  stretcli  and  loosen  il.  If,  after  the  handa.tije  dries,  the  patient 
complains  of  its  cutting,'  liis  ear,  a  drop  of  \asclin  just  at  the  spot 
will  soften  the  netting  there  and  i^ive  relief.  It  should  not  be 
nicked  with  knife  or  scissors. 


Fig.  9. — Profile  vie 

of  engagi 


of  nioiiocular  Ijandagc  to  show  manner 
Ing  occipital  prominence. 


The  Double  or  Binocular  Roller. — (Fi.i,'.  10.)  The  pad  is 
put  on  each  eye  and  a  wad  of  cotton  laid  between  them  at  the  base 
of  the  nose.  The  bandage  is  started  in  the  same  manner  as  the 
single,  but  after  the  iirst  turn  around  the  head  the  strip  is  carried 
downward  over  the  center  of  the  pad  covering  the  left  eye  (the  right 
being  the  operated  eye).  It  passes  thence  round  the  base  of  the 
occiput — under  the  right  ear,  upward  over  the  right  pad — again 
round  the  occipital  prominence,  again  downward  over  the  left  pad, 
and  so  on.  It  will  be  seen  that  this  is  a  regular  figure-of-S  bandage. 
After  three  turns  over  each  ])a(l  the  remain<ler  is  carried  straight 
around  the  head,  to  ll.x  the  whole,  and  pinned.  Xow,  if  a  dab  of 
flexible  collodion  be  jnit  on  tlie  thin  places  in  the  bandage  here  and 


20  PARA-OPERATIVE    TECHNIC 

there  about  the  forehead  and  cheek  the  most  restless  patient  cannot 
disturb  it  under  48  hours.  This  applies  to  the  single  or  the  double 
bandage  or  the  tie.  For  extractions,  and  other  particular  cases, 
in  addition  to  the  dabs  of  collodion,  it  is  my  custom  to  paste  on  a 
strip  of  gauze,  half  over  the  nose  and  half  over  the  bandage,  as  in 
Fig.   II.     This  not  only  helj)s  to  secure   the  dressing,  but,  better 


Fig.  10. — Binocular  bandage. 

Still,  prevents  the  patient  from  fingering  the  eye  and  from  lifting 
the  bandage.  It  must  be  borne  in  mind  that  the  netting  bandage 
loosens  up  a  trifle  upon  drying,  hence  it  must  be  a  little  tight  when 
freshly  applied.  When  the  jjalient  is  lying  on  the  table  the  head 
is  held  up  free  for  the  bandaging — not  by  any  cjfoyt  of  his  oivn — 
but  by  an  aid,  one  of  whose  hands  is  placed  on  the  top  of  the  head, 
fingers  pointing  backward,  and  the  other  beneath  the  chin.  In 
this  way  the  hands  are  not  in  the  way  of  the  bandaging. 
Adhesive  plaster  as  a  means  of  holding  eye-dressings  in  place 


NON-STICKING    FILMS  21 

has  been  considerably  used.     In  conncclion    with   i^'auze  it  does 
very  well,  but  with  cotton  it  makes  a  nasty  mess. 

Non-sticking  Films.— Cotton  and  ,ii;au/.c  ha\c'  the  unfortunate 
property  of  bccomin<];  firmly  adherent  to  a  bk'e(nn<;  wound,  or  a 
raw  surface,  when  kcijt  in  contact  for  a  few  hours.     This  constitutes 


Fig. 


-Eandage  sealed  with  coUodionized  siri 


a  decided  objection,  especially  in  dressings  applied  after  plastic 
operations  wherein  mucous  or  cutaneous  grafts  are  employed. 
Despite  the  utmost  pains  in  removing  the  dressing — long  soaking, 
etc. — the  graft  may  be  loosened  by  traction  of  the  adherent  fibres, 
and  perish  in  consequence.  To  prevent  this,  Narious  substances 
have  been  placed  next  to  the  wound.  \'asclin,  for  example,  or 
a  mixture  of  one  part  paraffin  to  4  parts  of  vaselin  may  be  smeared 


22 


PARA-OPERATIVE    TECHNIC 


onto  the  already  moistened  Him  of  cotton.  Better  still  is  a  layer 
of  luie  gutla  percha  tissue  or  the  thinnest  of  gold-beater's  skin, 
l)ut   the  tissue  or  the  skin  must   contain  a  series  of   small   slits  to 


-Monocular  natch. 


Fig.  13. — Binocular  patch. 


insure  proper  drainage.  Pieces  of  these  are  kept  ready  in  a  jar  of 
some  appropriate  antiseptic  solution.  If  the  solution  is  of  a  kind 
that  is  irritating  to  skin  or  flesh  the  film  is  washed  with  warm 
boric  or  salt  solution  just  before 
applying. 

Patches. — These  are  among  the 
various  devices  for  taking  the  place 
of  the  bandages.  Like  the  bandages, 
they  are  made  monocular  or  binocular, 
and  of  white  or  black  cotton  or  silk. 
Figs.  12  and  13  show  forms  of  single 
and  double  patch  devised  by  Dr. 
Agnew,  of  New  York,  and  first  used 
at  the  Manhattan  Eye  and  Ear  Hos- 
pital. The  single  patch  is  of  black 
sateen,  two  thicknesses,  with  stiffen- 
ing between.  It  is  oval  in  shape,  the 
tape  being  attached  in  the  long  axis  of  the  oval.  The  double  one 
is  black  sateen  outside,  with  white  lining.  Unlike  the  oval  patch, 
it  contains  no  stiffening.  lUAh  are  furnished  with  black  tai)e  for 
tying  on,  the  last-described  having  a  piece  fast  to  each  of  the  four 
corners.     It  has  a  notch  for  the  nose.     The  tape  for  all  patches, 


-Monocul; 


PROTECTIVE    MASKS 


23 


shades,  and  shields  sliould  be  left  lonu;  on  onr  side  and  short  on  the 
other,  so  that  the  knot  will  he  al  the  >i(le  ol"  the  liead  rather  than  at 
the  back.  Fig.  14  represents  a  patch  much  emijloyed  at  the  Illinois 
Eye  Infirmary.  Beneath  each  is  worn  the  regulation  dressing,  as 
described  further  back.  Indeed,  the  object  of  all  bandages  and 
their  substitutes  is  merely  the  holding  of  the  dressing  in  place. 


?"if;.  15. — Rins^f's  maslc  over  Ijinocular  l)andagc. 

Protective  Masks  and  Shields.— Many  an  operated  eye, 
particularly  after  extraction,  has  been  injured  by  a  knock  or  a 
blow  received  on  top  of  both  bandage  and  dressing.  It  was  to 
prevent  such  accidents  that  these  were  devised.  One  of  the  best 
is  the  mask  given  by  the  late  Frank  Ring,  of  New  York,  and  shown 
in  Fig.  15,  It  is  of  sateen— black  without  and  white  within. 
It  is  treated  with  a  heavy  size  in  the  making,  then  moulded  into 
form,  and  can  withstand  considerable  pressure  without  indenting. 
There  are  large  concavities  to  receixe  the  dressings,  it  fits  nicely 


24  PARA-OPERATIVE    TECHNIC 

over  the  nose  and  is  held  on  by  four  strings  of  black  tape.  Although 
it  is  made  double,  or  binocular,  it  can  easily  be  adapted  to  a  single 
eye-dressing  by  merely  cutting  a  good-sized  hole  on  the  side  of  the 
eye  left  open.  Unfortunately,  one  will  serve  for  a  single  case  only, 
which  is  a  slight  drawback  in  a  large  charitable  hospital,  though 
not  in  private  practice,  as  the  mask  is  not  expensive.  I  have  long 
had  in  mind  the  idea  of  having  made,  after  the  Ring  model,  an 
aluminum  mask,  but  with  a  circular  opening  ready-made  at  the  cen- 
ter of  each  of  the  dressing  concavities.  Say  these  openings  were 
one  inch  or  an  inch  and  a  quarter  in  diameter,  the  mask  would 
still  afford  ample  protection  from  the  usual  sources  of  injury,  and 
would   be   adapted   to   either   monocular   or   binocular   dressings. 


Fig.  1 6. — Fuchs'  wire  mask. 

They  could  be  manufactured  economically  by  the  stamping  process, 
would  be  light,  and  could  be  cleansed  and  used  over  and  over, 
indefinitely.  Emerson,  of  New  York,  has  also  devised  a  practical 
protective  mask.  It  is  of  wire,  and  in  form  is  almost  a  counter- 
part of  that  of  Ring.  Fig.  i6  shows  the  monocular  wire  mask  of 
Fuchs.  This  is  also  made  in  binocular  form.  The  last  admit  of 
vision  in  the  unoperated  eye  if  the  dressing  is  left  oft".  Figs.  17 
and  18  represent  rather  cumbersome  modifications  of  the  Fuchs 
masks.  Any  of  these  may  be  used  without  the  bandage,  or  the 
intervening  cotton  pad,  or  other  dressing.  Fig.  19  gives  an  idea  of 
the  metallic  shield  of  Snellen.  It  is  a  shell-shaped  contrivance  with 
openings  through  which  run  the  white  tape  by  which  it  is  kept  in 
position. 

Shades. — x\fter  the  eye  has  sufilciently  recovered  to  leave  off  the 
dressing  it  is  usually  not  in  condition  to  be  exposed  at  once  to  the 
full  glare  of  light,  to  the  air,  and  to  the  dust.  Then  it  is  that  shades, 
goggles,  and   coquilles  are   put  on.     Shades   also    arc  monocular 


I'ROTECTIVE    GLASSES 


25 


or  binocular.  Single  shades  are  made  of  celluloid,  llesh  tinted,  or, 
like  the  patch,  of  black  silk,  double,  and  with  cardboard  between 
the  two  layers.  Double  shades  are  most  often  made  like  the  visor 
of  a  cap,  and  are  of  celluloid  or  papier  machc.  They  are  not  worn 
to  hold  dressings  in  place  and  none  should  ever  be  placed  beneath 
them.  Any  handy  seamstress  can  make  the  single  shades,  the 
necessary  materials  being  tougli   cardboard   for  stiffening,   black 


Fig.  17. — Wire  shield,  or  mask,  for  one  eye.     Over  monocular  bandage. 

silk  or  satin  for  covering,  and  black  tape  for  tying  on.  They  are 
usually  made,  a  number  at  a  time,  by  the  nurses  or  other  attendants 
about  hospitals,  are  sterilized,  used  for  a  single  patient,  for  a  few 
days,  then  destroyed.  The  tape  is  tied  straight  around  the  head, 
just  above  the  eyebrows,  and  the  shade  hangs  in  front  of  the  eye 
^vithout  touching  even  the  lashes.     Fig.  20. 

Protective  Glasses. — These  are  mounted  either  as  spectacles 
or  nose-glasses — pincc  ncz.     They  are  either  plain  glass  or  lenses 


26 


PARA-OPERATIVE    TECHNIC 


to  suit  the  peculiar  refraction  of  the  wearer.  In  many  instances 
the  glasses  are  flat  and  of  ordinary  size,  but  they  fuliill  their  office 
better  if  they  are  decidedly  concavo-convex  and  of  extra  large  lateral 
dimensions.  These  are  called  coquilles.  They  should  never  be 
of  pressed  or  moulded  glass,  as  they  are  then  irregular  concave 
lenses,  which  are  very  trying  to  the  eyes,  but  should  be  ground 
into  the  proper  form.     Their  protective  qualities  are  due  to  their 


Fig.  i8. — Double  wire  mask. 


color.  Formerly,  they  were  shades  of  green,  then  of  blue,  then  of 
violet;  later  they  were  graded  "smoke,"  or  gray;  and  now  orange 
or  amber  is  de  regie.  Theoretically,  they  should  be  either  deep 
amber  or  orange-scarlet  or  gray.  In  tlic  first  two  instances  they 
would  act  as  ray-filters  to  eliminate  the  actinic  and  irritating  portion 
of  the  light,  viz.,  the  violet  and  ultra-violet;  as  do  the  gray-green 
glasses  recommended  by  Holla uer,  of  Basle,'  or  those  of  the  tint 
'  Archives  of  Opli.,  Jan.,   lyio. 


CLEANSING    AND    REDKESSING 


27 


called  "chlorophilc. "  In  the  second,  ihcy  would  merely  serve, 
according  to  the  density  of  the  gray,  to  reduce  the  intensity  of  the 
light.  It  is  desirable  in  fitting  coquilles  to  have  them  sit  as  close  as 
possible  to  the  eyes  not  to  touch  the  lashes. 

Goggles. — The  original  of  these  were  of  plain  glass — green  or 
blue — surrounded  by  wire  screens  that  rested  snug  against  the  lids, 
the  whole  being  held  in  place  by  a  rubber  band  around  the  head. 
Villainous  things  they  were,  too.     Of  recent  years,  especially  since 


Fi< 


.la.i^i 


the  advent  and  rise  of  the  automobile,  there  has  been  a  veritable 
deluge  of  different  improved  styles,  so  that  one  were  hard  to  please 
if  he  cannot  be  suited  with  a  pair. '  Their  glasses  may  be  had  in  any 
tint,  and  some  of  them  arc  about  all  that  could  be  desired  in  the 
wav  of  ])rotectivc  glasses. 

Cleansing  and  Redressing.     .\11  the  beneficient  results  hoped 
for   from   a   given   surgical   operation    have   often   cither   not   been 


28 


PARA-OPERATIVE    TECHNIC 


realized  or  have  been  turned  to  actual  disaster  by  inattention  to 
some  essential  detail  in  the  more  immediate  after-treatment.  Many 
a  prolapse  of  the  iris  after  extraction,  for  example,  has  occurred 
through  carelessness  on  the  part  of  the  one  who  removes  the  first 
dressing  and  applies  the  second.  It  is  also  safe  to  assert  that  sim- 
ilarly many  an  eye  has  been  infected.  The  inconsistence  of  a 
large  proportion  of  surgeons  as  regards  their  attitude  toward  the 
patient  at  the  time  of  the  operation  and  after  the  same  is  curious 
to  behold.  During  the  first  few  days  not  only  is  skill  and  care  in 
handling  needed,  but  trained  supervision  as  well,  to  the  end  that  the 
first  signs  of  threatened  complications  may  be  detected  in  good  sea- 
son. When  practicable,  the  patient  is  taken  to  a  room  especially  pre- 
pared for  the  dressing — that  \s,  favorably  prepared — for  a  room  used 
only  for  such  purposes  might  be  the 
least  favorable.  The  air  of  the  apart- 
ment must  be  as  free  as  possible 
from  dust.  Great  tact  is  resorted 
to  in  properly  adjusting  the  patient's 
mental  state  to  the  occasion,  for  there 
is  often  more  apprehension  relative 
to  "the  first  dressing"  than  to  the 
operation  itself.  Persons  of  consider- 
able intelligence  are  apt  to  have  very 
vague  notions  as  to  what  it  means  to 
have  the  eye  "dressed,"  and  a  few 
words  in  explanation  serve  to  relieve 
the  situation  as  regards  all  concerned. 
Everything  needed  must  be  thought 
of  and  at  hand.  Towels  are  put  around  the  patient's  neck 
and  around  the  head  to  cover  the  hair,  and  a  catch-basin  is 
placed  beneath  the  chin.  In  most  instances  it  pleases  the  patient 
to  be  allowed  to  hold  the  basin,  as  he  feels  that  he  is  helping  the 
cause.  He  is  cautioned  to  keep  both  eyes  gently  closed,  and  not 
make  any  effort  to  open  them  until  told  to  do  so,  and  that  he  must 
never  squeeze  them.  The  bandage  is  cut,  and  is  so  stripped  off 
as  to  leave  the  pad  of  cotton  covering  the  eye.  This  is  usually 
stuck  more  or  less  tightly  to  the  lids,  so  as  to  require  soaking  slightly 
by  dropping  warm  boric  acid  solution  behind  it  with  a  dropper 
to  make  it  let  go.  After  cutting  and  removing  the  bandage,  and 
placing  the  towel  over  the  hair,  it  were  best  that  the  dresser  put 


Fig.  20. — Monocular  shade. 


REDRESSING  29 

on  a  pair  of  sterilized  ru1)ber  gloves.  I  know  this  is  seldom  done, 
but  it  is  the  proper  thins^.  The  warm  solution  for  use  with  the 
cotton  sponges  is  in  a  glass  llask  or  in  an  ordinary  eight-ounce 
bottle.  From  this  it  is  poured  ui)on  the  sponges,  over  the  catch- 
basin.  It  does  not  comport  wiili  true  cleanliness  to  dip  the  sponges 
into  a  vessel  of  liquid  with  the  lingers,  especially  if  they  be  not 
gloved.  Always  warn  the  dressee  as  to  what  is  about  to  be  done. 
The  mere  touching  of  a  finger  to  the  forehead  or  of  a  sponge  to  the 
lids  might  otherwise  cause  a  tremendous  start  and  a  squeeze.  He 
is  also  told  not  to  put  up  the  hands.  What  follows  here  refers 
mainly  to  rases  where  the  operation  has  been  upon  the  globe.  The 
first  sponge  is  made  dripping  wet.  It  is  oblong,  and  one  end  is 
allowed  to  project  well  beyond  the  tips  of  the  fingers  to  avoid  giving 
the  eye  an  unguarded  poke  or  thump.  This  loose  end  is  raked 
gently  back  and  forth  over  the  eyelashes  to  soften  the  dried  dis- 
charges from  the  eye  accumulated  along  the  palpebral  fissure. 
FolloW'ing  this,  another  sponge,  but  wrung  dry  this  time,  is  lightly 
drawn  along  to  drink  up  the  moisture  clinging  to  the  lashes.  After 
the  first  sponge,  all  of  them,  while  wet,  must  yet  be  in  a  more  or 
less  absorbent  condition — that  is,  they  should  take  from  the  parts 
they  touch  rather  than  give.  Observance  of  this  point  j^revents 
driving  polluted  solution  from  without  into  the  eye.  Several  wet 
sponges  are  used  about  the  lids,  brow,  nose,  cheek,  and  temple, 
always  beginning  at  the  center  of  the  area  to  be  washed  and  ending 
at  the  periphery,  i.e.,  never  going  back  to  the  lids  or  to  the  cilia 
with  a  bit  of  cotton  that  has  touched  the  adjacent  surfaces.  A 
sponge  is  never  re-wetted  and  again  applied.  By  way  of  a  finish,  a 
pledget  is  squeezed  hard,  and  with  it  the  parts  are  sponged  to  free 
from  drops.  The  lids  of  the  unbandaged  eye  are  also  often  glued 
together,  so  that  it,  too,  should  be  bathed,  then  opened,  by  the 
dresser — not  by  the  dressee.  With  oblong  sponge  in  the  fingers 
of  one  hand  one  proceeds,  with  the  thumb  of  the  other  placed  over 
the  upper  rim  of  the  orbit,  gingerly  to  lift  the  hd  of  the  operated 
eye.  If  it  is  still  stuck  the  wet  sponge  is  again  brought  into  requisi- 
tion; meantime  repeating  the  command  that  the  patient  make  no 
attempt  to  move  the  lids  himself.  When  it  is  seen  that  both  eyes 
are  free  to  open  he  may  be  asked  in  a  quiet  manner  to  open  the  eyes 
and  to  look  in  any  desired  direction,  and  to  avoid  snapping  and 
nipping  of  the  lids.  Having  been  assured  that  the  patient  has  proper 
control  of  the  lids,  one  may  proceed  more  thoroughly  to  cleanse 


30  PARA-OPERATIVE    TECHNIC 

lashes,  free  borders  and  canthi;  using  the  long  end  of  sponge. 
Cleansing  and  inspection  are  made  to  consume  the  shortest  time 
consistent  with  prudence,  not  to  expose  the  eye  unnecessarily  to 
harmful  agents.  Whatever  is  indicated  in  the  way  of  medication 
or  other  attention  is  now  disposed  of  and  the  eye  re-dressed  as  per 
instructions  given  under  "Bandaging."  Each  time,  as  one  is 
about  to  make  the  application,  irrigation,  instillation,  or  the  like, 
it  is  made  known  to  the  patient  what  to  expect.  It  is  neither  safe 
nor  pleasant,  as  regards  the  party  most  directly  interested,  to  have 
things  put  into  and  upon  the  eyes  without  any  sort  of  warning, 
even  when  deftly  and  gently  done.  How  much  worse,  then,  to 
have  them  dropped  from  heights,  squirted  forcibly,  and  shot  in, 
or  dabbed  on  with  a  splash! 

The  Removal  of  Sutures. — It  is  a  curious  fact  that  there  is  al- 
most as  much  dread  of  this  performance  on  the  part  of  our  patients 
as  of  the  operation  that  makes  it  necessary.  Sometimes  there  is 
even  more.  This  is  something  they  have  not  counted  upon  and 
nerved  up  for,  and  it  is  faced  with  a  poorer  grace  in  consequence. 
Hence,  great  adroitness  is  often  required  to  bring  them  to  the  point 
of  calm  submission.  They  must  be  disabused  of  the  idea  that  the 
thread  is  tightly  adherent  to  the  flesh  and  that  the  instruments  are 
put  in  actual  contact  with  the  parts  involved.  On  the  other  hand, 
it  is  well  to  have  impressed  upon  them  the  dangers  of  leaving  the 
sutures  in  situ  after  the  lapse  of  a  certain  period.  Indeed,  this  is 
not  a  sophism  got  up  merely  to  influence  the  mind.  Sutures  should 
be  got  rid  of  just  as  soon  as  they  have  served  their  purpose,  and 
this  is  much  earlier  than  many  seem  to  suppose.  After  that  they 
not  only  continue  to  act  as  foreign  bodies  but,  worse  yet,  they, 
together  with  their  canals,  form  most  alluring  open  roads  for  the 
entrance  and  growth  of  bacteria.  Ordinary  cutaneous  and  con- 
junctival sutures  ought  not  to  remain  longer  than  48  hours.  A 
few  special  ones,  such  as  advancement  and  ptosis  sutures,  would 
better  be  left  longer — from  4  to  8  days.  If  the  sutures  are  outside 
of  the  conjunctival  sac  they  are  first  softened  and  cleansed  with  a 
moderately  strong,  warm,  antiseptic  solution,  and  wiped  fairly  dry. 
The  most  suitable  instruments  for  the  purpose,  to  my  mind,  are  a 
pair  of  small,  but  stiff,  dressing-forceps  and  a  pair  of  small,  blunt- 
pointed  scissors,  curved  on  the  flat — Stevens'  stral)ismus  scissors, 
for  example.  Toothed  forcc])s  do  not  seize  the  tliread  readily. 
It  is  indispensable  that  the  scissors  cut  well  at  the  very  extremity 


SPONOKS  31 

of  the  blades.  It  is  best  to  ha\e  (he  ])alienl  |)r()ne  upon  the  table, 
though  he  may  sit  U])riglit.  In  either  case  the  head  would  better 
be  steadied  by  an  assistant.  The  same  helper  may  also  hold  the 
lids  apart  when  the  sutures  are  inside  the  pal[)ebral  hssure.  But, 
in  the  latter  case,  unless  one  is  pretty  sure  of  his  patient,  and  his 
assistant,  it  were  better  to  use  a  blepharostat  at  once,  the  eye  having, 
of  course,  been  cocainized.  The  operator  steadies  the  hands  on 
some  contiguous  part,  and  watches  closely  the  tendency  of  the 
operated,  so  as  to  be  in  the  closest  touch  in  order  to  anticipate 
moves  or  to  move  with  him,  thus  avoiding  sudden  jerks  upon  the 
thread.  In  taking  out  cutaneous  sutures  an  end  of  thread  is 
grasped  with  the  forceps  and  so  pulled  upon  as  to  draw  the  suture 
well  out  of  its  canal  on  that  side;  it  is  then  cut  close  up,  the  scissors 
being  held  with  the  convexity  of  the  blades  upward.  In  this 
manner  one  obviates  pulling  a  soiled  portion  of  thread — a  part  that 
has  lain  on  the  outside  of  the  skin — through  the  entire  stitch  canal, 
to  possibly  infect  it.  A  wet  cotton  sponge  is  held,  or  laid,  con- 
veniently near,  on  which  to  wipe  forceps  or  scissors.  There  is 
usually  slight  bleeding  which  may  require  sponging.  The  stitches 
all  removed,  the  parts  are  again  bathed  with  the  antiseptic  and 
sponged. 

Sponges. — The  natural  sponge,  as  a  part  of  the  surgeon's 
armentarium,  is  a  thing  of  the  past,  having  been,  quite  properly, 
superseded  by  the  artificial  kinds.  They  are  made  chiefly  of  cotton 
or  gauze— preferably  the  former.  Indeed,  gauze  sponges  are 
seldom  used  in  eye  surgery.  The  regulation  shape  is  fusiform,  and 
the  sponges  vary  in  size  according  to  the  nature  of  the  operation 
with  which  they  are  to  be  used.  Those  destined  for  the  surgery 
of  the  conjunctiva  and  the  globe  are  the  smallest,  measuring, 
when  freshly  wrung,  about  two  inches  from  tip  to  ti]),  and  one- 
half  inch  across  at  the  middle.  For  operations  upon  the  lacrimal 
apparatus,  for  enucleations  and  the  grosser  plastic  operations  they 
are  larger,  and  less  fusiform.  Tlie  properly  most  essential  in  a 
sponge  is  great  absorptivity.  It  is  not  alone  suiTicient  that  the 
cotton  from  which  it  is  made  is  highly  absorbent,  the  sponge  must 
be  compressed  and  damp.  Dry  cotton,  no  matter  how  fitting  the 
quality,  lacks  this  property;  and  so  does  damp  cotton  if  in  a  loose 
wad.  Besides,  dry  cotton  is  most  objectionable  in  surgery  because 
of  the  detached  fibres  getting  into  the  wound  and  clinging  to  the 
instruments.     To  the  most  effective  the  si)onge  must  be  nncly  and 


32  PARA-OPERATIVE    TECHNIC 

tightly  wrung  out  of  the  solution  with  which  it  is  impregnated.  It 
is  a  mistake,  therefore,  to  make  and  wring,  then  sterihze  them  in  the 
autoclave,  and  consider  them  ready  for  use.  They  are  made  too 
dry  and  too  loose  in  this  way.  They  should  be  freshly  prepared 
from  sterilized  cotton.  The  hands  of  the  one  who  makes  them 
are  clad  in  aseptic  rubber  gloves.  Pieces  of  suitable  size  are  pulled 
from  the  roll  of  cotton  and  fashioned  into  shape  by  the  fingers 
and  by  rolling  with  the  palms.  They  are  then  dropped  into  the 
antiseptic  solution,  covered  securely,  and  left  there  till  needed, 
when  they  are  wrung  again  with  the  gloved  hands,  a  few  at  a  time 
and  put  on  or  in  some  sort  of  server.  It  should  be  remembered 
that  the  tips  are  the  working  parts,  hence,  they  should  be  handled 
at  their  middles  by  both  the  surgeon  and  the  aid  who  passes  or 
uses  them.  By  the  operating  table  is  an  enameled  jar  with  in- 
verted cone  for  cover,  and  truncated  by  an  opening.  Into  this 
the  discarded  sponges  are  dropped,  and  not  scattered  promiscuously 
all  around.  Nurses  and  assistants  need  considerable  training  in 
the  matter  of  sponging  before  venturing  to  help  in  this  capacity 
at  an  operation.  It  is  no  mean  art.  They  must  know  when  to 
take  the  initiative,  and  when  to  wait  for  an  order  to  apply;  when 
to  hold  out  the  sponge  for  the  operator  to  wipe  an  instrument  upon, 
etc.  The  corneal  epithelium  is  to  be  spared  contact  with  the  sponge 
whenever  practicable. 

Applicators,  Brushes  and  Swabs.— An  applicator  may  be  of 
metal  or  wood.  It  serves  merely  at  the  handle  for  a  brush  or  a 
swab.  Of  the  metals  silver  is  probably  the  best  adapted  to  the 
purpose.  Excellent  wood  applicators  are  found  ready  made  in 
tooth-picks,  especially  those  made  of  bamboo,  called  Japanese. 
The  great  advantage  of  these  is  their  extreme  cheapness,  admitting 
of  throwing  away  after  once  using.  Whatever  the  material,  the 
eye  applicator  must  be  delicate  and  light.  One  and  one-half  to 
two  mm.  thick  at  the  large  end,  thence  gradually  tapering  to  a  point, 
or  nearly,  and  ten  to  twelve  centimeters  in  length.  Not  infre- 
quently metal  applicators  are  seen  that  are  roughened,  or  nicked, 
for  a  short  distance  from  their  working  ends.  This  will  do  in  a 
wooden  one,  that  is  not  used  a  second  time,  but  is  a  serious  draw- 
back in  a  metal  one,  for  reasons  given  further  along.  The  same 
objections  may  be  urged  to  the  probe,  or  bulbous  pointed  applicator. 
Formerly,  camels'  hair  brushes  were  used  in  the  treatment  of  eyes. 
In  the  light  of  modern  medical  science  they  would  be  deemed  abomi- 


SWABS    AND   BRUSHES 


33 


nations,  and  justly  so.  The  ideal  brush,  or  swab,  is  now  made  of 
absorbent  cotton  wound  onto  an  applicator.  It  all  lies  in  the  manner 
of  the  winding  whether  the  brush  or  a  swab  is  the  result.  The 
difference  between  the  two  is  just  what  the  names  imply — the 
brush  ha\ing  a  pliant  free  end  and  the  swab  being  a  compact  bunch. 
To  make  a  brush  a  small  quantity  of  cotton  is  taken  from  the  roll 
and  its  irregularities  of  outline  are  pulled  off  till  it  assumes  the 
square  shape  shown  in  Fig.  21.  It  is  so  held  between  the  left 
thumb  and  index  that  the  fibres  composing  it  run  horizontally. 
The  small  end  of  the  apphcator  is  laid  diagonally  across  the  upper  right 
hand  corner  (Fig.  21  a),  and  the  shaft  of  the  applicator  is  revolved 
with  the  other  thumb  and  index  away  from  the  maker,  at  the  same 
time  the  right  thumb  and  finger  help  the  instrument  to  get  hold  of 


Fig. 


-a,  Ti)  make  a  brush,     b,  To  make  a  swat 


the  extreme  corner  fibres  of  the  cotton.  As  soon  as  these  begin 
to  wind  on,  the  left  thumb  and  index  take  a  firmer  hold  on  the  cotton, 
to  make  the  winding  tight.  All  that  remains  is  to  continue  turning 
the  applicator  till  all  the  cotton  is  wound  on,  and  the  brush  is  made. 
If  it  seems  too  long  or  uneven,  the  fibres  are  pulled  out  till  it  assumes 
the  proper  dimensions.  To  make  a  swab  or  firm  mop,  one  takes 
the  same  thin,  square  bit  of  cotton,  but  before  starting  to  turn  the 
applicator,  which  is  laid  on  just  as  for  the  brush,  the  fibres  are  made 
to  run  in  the  vertical  sense  (Fig.  21  b).  The  winding  is  begun  as 
before,  but  when  it  has  got  well  under  way,  the  fibres  that  would 
otherwise  project  beyond  the  end  of  the  shaft,  are  turned  back- 
ward by  the  left  index,  and  the  turning  kept  up  until  all  the  cotton 
is  on  and  smoothed  down  into  a  good,  firm,  rounded  mass.  In 
both  instances  the  cotton  is  wound  on  very  tightly.  In  this  way  the 
implement  will  bear  sterilization.  No  roughening  is  needed  to 
keep  the  cotton  from  slipping  off.     If  made  properly,  the  cotton 


34  PARA-OPERAXrV^E    TECHNIC 

will  only  come  off  by  unscrewing  it,  as  it  were,  i.e.,  turning  the 
shaft  in  the  opposite  sense,  or  toward  one.  In  this  way  it  may  be 
stripped  off"  at  once,  whereas  if  the  shaft  is  roughened  the  cotton 
will  not  strip.  The  brush  is  employed  when  the  remedy  is  to  be 
painted  or  penciled  on,  the  swab  when  it  is  to  be  rubbed  on.  The 
swab  is  also  useful  in  putting  ointment  into  the  eye,  as  well  as  for 
rubbing  it  on. 

Droppers. — By  the  term  eye-dropper  is  commonly  understood 
the  combination  of  small  rubber  bulb  and  glass  tube  with  narrowed 
extremity.  The  word  pipette  is  sometimes  used  as  interchangeable. 
The  last  is  literally  "Httle  pipe,"  and  refers  to  the  old  medicine 
dropper,  or  drop-counter,  which  consists  of  a  glass  tube  without 
the  rubber  bulb.  The  small  end  of  the  tube  is  immersed  in  the 
liquid  and  when  enough  has  flowed  in,  the  finger  is  clapped  onto 
the  larger  end.  The  tube  may  then  be  lifted  out  and  no  liquid 
will  escape  till  the  finger  is  raised.  Both  appliances  are  useful  in 
ophthalmic  practice.  The  pipette  is  only  adapted  to  the  gentle 
instillation  of  one  or  several  drops,  while  the  eye-dropper  may,  in 
addition,  be  used  for  a  forceful  and  copious  flushing.  This  is  true, 
at  least,  of  those  with  the  larger  bulbs,  for  glass  and  rubber  can 
both  be  filled.  Those  with  tiny  bulbs  are  specially  designed  to 
make  it  impossible  to  fill  them  full — an  admirable  thing  in  an 
unsterilized  dropper,  as  the  rubber  cavity  contains  a  powder  that 
contaminates.  Whether  the  narrowed  extremity  is  curved  or  straight 
makes  little  difference,  though  the  straight  one  is  more  easily  cleaned, 
and  will  enter  more  readily  into  the  mouths  of  vials.  The  smaller 
the  opening  in  the  end  and  the  sharper  the  end  itself,  the  smaller 
the  drop  that  is  formed,  and  small  drops  are  sometimes  preferable 
to  large  ones.  The  pipette  is  free  from  some  of  the  annoyances 
caused  by  the  rubber,  is  easily  sterilized,  and  is  sure  to  work  and  not 
to  leak.  Who  has  not  seen  the  dropper,  in  careless  hands,  made 
to  suck  back,  by  relaxing  the  hold  on  the  rubber  bulb  while  the 
tip  is  in  fluid,  like  blood,  or  pus?  In  truth,  allowing  the  tip  of 
either  dropper  or  pipette  to  actually  touch  the  parts  is  inexcusable. 
Much  vexation — even  calamity — has  been  caused  by  getting 
droppers  mixed,  putting  borric  acid  solution,  for  example,  into 
a  glaucomatous  eye  with  a  dropper  that  has  been  used  for  atropin 
solution.  To  obviate  this,  the  bulb  may  have  marked  upon  it,  with 
indelible  ink,  the  name  of  its  particular  drug;  or  the  rubber  may  be 
of  a  different  color  for  each  of  the  more  mischief-making  solutions. 


INSTILLATION 


35 


The  method  of  instilling  drops  with  cither  the  cyc-droi)j)cr 
or  the  pipette  deserves  a  word.  A  few  drops  care  drawn  into  the 
glass  tube,  the  forefinger  of  the  free  hand  is  placed  just  beneath 
the  lower  lid,  which  is  lightly  depressed,  to  open  the  lower  cul-de-sac, 
the  patient  is  told  to  look  upward,  the  dropj)cr  is  approached  till 


Fig.  22.--ALinncr  of  inakiii'/  instillation  with 


its  tip  is  about  one-eighth  of  an  inch  above  the  center  of  the  free 
border,  when  a  drop  is  squeezed  out  and  allowed  to  touch  at  that 
point.  It  immediately  enters  the  conjunctival  sac — attracted  by 
the  moisture  on  the  inner  side  of  the  lid  (Fig.  22).  If  the  patient 
cannot  control  the  lids,  the  middle  fmger  holds  up  the  upper  lid 
while  the  index  depresses  the  lower.     In  cases  of  children  and 


36  PARA-OPERATIVE    TECHNIC 

excessively  touchy  persons,  it  is  made  easier  by  putting  them 
flat  on  their  backs.  The  drops  should  never  fall  from  a  height, 
but  should  either  be  made  to  touch  the  free  border,  or  be  let  fall  a 
few  millimeters  only  into  the  inner  canthus.  If  the  cul-de-sac  is 
full  of  tears,  the  drop  will  simply  cause  an  overflow  and  be  wasted. 
A  sponge  is  first  used  to  exhaust  the  tears.  The  systemic  effects 
of  poisonous  instiflations  can  be,  in  great  measure,  prevented  by 
having  the  patient  compress  the  canaliculi  with  the  forefinger. 
It  need  hardly  be  urged  that  the  finger  must  be  there  before  the 
drop  is  put  in,  else  the  first  winking  of  the  lids  will  draw  the  solution 
into  the  lacrimal  sac.  This  precaution  is  especially  advisable  when 
the  instillations  are  repeated  in  quick  succession. 
^Irrigators  or  Douches. — These  refer  to  various  appliances  by 
which  quantities  of  liquid  are  brought  into  contact  with  the  eye  for 


Undine,     b,  Morax  compte-gouttes.     c,  Wickerkiwicz 
douche,     d,  Tumbler  to  show  relative  size. 

therapeutic  purposes.  They  work  by  (i)  pouring,  as  from  special 
vessels,  the  stream  being  directed  by  a  spout  and  controlled  by  placing 
the  finger  as  a  valve  over  a  separate  opening;  or  by  (2)  gravity, 
as  from  elevated  reservoirs,  when  the  stream  is  directed  by  a  rubber 
tube  and  controlled  by  compressing  the  tube;  or  by  (3)  ejection,  as 
from  some  form  of  syringe,  in  which  the  stream  is  directed  as  in 
either  of  the  foregoing,  but  is  controlled  by  pressure  upon  a  rubber 
bulb.  To  the  first  belong  the  divers  glass  and  enameled  flasks 
known  as  undines,  compte-gouttes,  etc.  (Fig.  23);  to  the  second,  the 
fountain  syringes,  the  percolators,  and  the  tube  syphons;  to  the  third, 
the  bulb  syringes,  bulb-syphons,  and  hand-sprays.  The  eye-dropper 
is  but  a  form  of  bulb-syringe.     The  glass  flasks  are  most  appropriate 


EYE    CUPS 


37 


for  gentle  washing  of  the  eye.  They  are  neat  and  eleanly,  and  the 
stream  is  gentle  except  they  be  held  loo  high.  They  are  necessarily 
of  limited  capacity  in  order  to  be  convenient  to  hold  with  one  hand, 
therefore  adapted  to  the  less  copious  and  prolonged  irrigations. 
Those  in  the  second  category  are  just  the  ones  designed  for  irriga- 
tion on  the  larger  scale.  The  reservoir  is  of  soft  rubber,  enameled 
metal,  or  glass,  and  may  be  of  any  desired  size.  Some  of  them  are 
quite  elaborate,  having  means  for  heating,  thermometer  attach- 
ment, etc.  Reservoirs  of  glass,  however,  will  always  appeal  more 
strongly  to  the  aseptic  instinct,  because  of  their  transparency, 
and  their  adaptability  to  all  modes  of  sterilization.  The  force  of  the 
stream  is  governed  by  the  height  to  which  the  source  is  elevated, 
and,  to  a  limited  degree,  by  compressing  the  tube  with  the  fingers. 
There  are  different  devices  by  which  the  licpiid  is  delivered  to  the 
eye  after  passing  through  the  rubber  pipe.  The  simplest  is  a 
nozzle  composed  of  the  glass  tube  of  an  eye-dropper.  Then  there 
are  the  multiple  vent-nozzles,  some  form  of  which  is  very  desirable 
in  irrigation  of  the  upper  cul-de-sac,  particularly  in  purulent 
conjunctivitis.  Among  the  simplest  is  one  of, 
glass,  celluloid  or  hard  rubber,  of  flattened, 
rounded  shape,  after  the  manner  of  Jaeger's  lid 
spatula,  with  several  openings  in  the  free,  or 
specialized,  end.  An  effective,  though  rather 
complex  attachment  is  the  irrigating  retractor  of 
Lagrange  (Plate  VIII,  No.  93).  x\s  to  the 
ejectors,  their  name  is  legion,  and  they  are,  on 
the  whole,  least  to  be  recommended,  as  they  are, 
for    the    most    part,    complex,    unreliable,    and  Fig.  24.— Agnew's  eye 

,  ,  r^,  11.1         c       si)ray  for  one  hand. 

bunglesome.  The  one  uncompounded  style  01  '  ^ 
this  class  is  the  rubber  bulb  alone,  or  the  bulb  with  glass  spout, 
as  represented  by  the  common  eye-dropper.  Their  streams  are 
steady,  intermittent,  or  broken  into  spray.  Among  the  last,  one  of 
the  least  objectionable  as  well  as  of  the  earliest,  was  suggested  by 
Agnew,  of  New  York,  and  is  known  as  the  Manhattan  Eye-douche 
(Fig.  24).  Its  extreme  compactness  enables  one  to  manage  it  easily 
with  one  hand. 

Eye  Cup  or  Bath.— This  is  the  primitive  douche.  It  is  a  small 
cup  whose  lip  is  designed  to  fit  snugly  just  within  the  bony  rim  of 
the  orbit.  It  is  filled  and  put  into  position  with  the  head  thrown 
far  forward— prone.     The  head  is  then   inclined  in  the  opposite 


38 


PARA-OPERATIVE    TECHNIC 


direction,  or  supine,  and  while  the  cup  is  held  close,  the  eye  is  al- 
ternately opened  and  shut.  This  serves  to  bathe  the  cornea  and 
part  of  the  ocular  conjunctiva,  but,  as  the  lids  fit  almost  water-tight 
to  the  globe,  the  lic^uid  does  not  reach  the  fornices  to  any  great 
extent. 

Irrigation  or  Douching. — All  solutions  must  he  freshly  made 
and  of  the  purest  ingredients  it  is  possible  to  obtain.  As  a  rule,  the 
liquid  for  the  procedure  is  warm,  ioo°  or  more.  It  is  thus  more 
agreeable  and  more  efficacious.  The  patient  may  sit  or  lie.  Towels 
are  placed  round  neck  and  over  hair.  A  catch-basin  is  held — 
usually  by  the  patient — to  catch  the  overflow\  If  the  posture  is 
sitting,  the  basin  is  held  as  in  Fig.  25,  except  that  it  is  put  more 


\ 


Fig.  25. — Manner  of  liolding  catch-basin.     Sitting, 

toward  the  side  upon  which  is  the  eye  that  is  being  treated.  The 
concavity  of  the  basin  is  held  tight  to  the  neck,  and  it  must  be  seen 
to  that  no  part  of  the  towel  gets  in  between  neck  and  basin,  so  as 
to  overhang,  or  project  above  the  rim,  for  this  would  form  a  drain 
that  would  lead  the  liquid  down  the  neck.  If  the  posture  is  lying, 
the  basin  is  held  close  beneath  the  ear  and  angle  of  the  jaw,  as  in 
Fig.  26.  Same  precautions.  The  lids  are  washed  and  sponged 
with  absorbent  cotton.  The  lids  are  everted,  one  at  a  time  or  both 
at  once,  and  the  warm  solution  poured  gently  on  them.     The  lids 


OINTMENTS 


39 


are  replaced,  the  upper  one  is  raised  by  placing  the  thumb  over 
the  upper  rim  of  the  orbit,  the  patient  is  made  to  look  down,  and 
the  stream  is  played  over  the  cornea  and  conjunctiva.  The  gaze 
is  then  ordered  upward,  the  lower  lid  is  depressed  by  the  index, 
and  the  lower  fornix  is  irrigated.  All  the  while,  the  vent  of  the 
irrigator,  whatever  the  kind,  is  held  close  up,  so  as  not  to  shock 
the  eye.  The  cornea,  in  particular,  soon  becomes  intolerant  of 
the  douching  unless  the  force  and  the  temperature  of  the  stream 
are  just  right.  A  very  strong  jet  is  justifiable  only  for  the  dislodg- 
ment  of  a  sticky  discharge.  Under  proper  conditions,  no  un- 
favorable reaction  follows  prolonged  and  copious  irrigation. 


Fig.  26. — Manner  of  holding  |)us-t)asin.      Recumbent. 

Ointments. — The  fatty  media  of  ointments  suitable  for  use  in 
the  eye  are  chiefly  vaselin,  lard,  castor  and  olive  oil,  and  lanolin, 
or  a  mixture  of  these  substances  with  varying  proportions  of  bees- 
wax or  paraflin,  to  give  greater  firmness.  They  keep  the  contained 
medicament  much  longer  in  contact  with  the  cornea  than  do  the 
aqueous  solutions,  hence,  prolong  the  effect.  Moreover,  they  do 
not  pass  through  the  lacrimal  canal,  so  that,  in  case  of  poisonous 
drugs,  such  as  atropin,  there  is  less  likelihood  of  intoxication,  which 


40 


PARA-OPERATIVE    TECHNIC 


makes  them  peculiarly  applicable  as  regards  children  and  women. 
As  this  is  not  a  chapter  on  ocular  therapeutics,  but  one  on  the 
technic  of  applications,  the  aim  here  is  to  indicate  the  manner  of 
handling  and  putting  the  ointment  into  the  eye.  The  most  con- 
venient, preservative,  and  sanitary  receptacle  for  the  ointment  is  the 
collapsible  tube  of  block  tin.  A  very  few  have  ingredients  that  are 
not  compatible  with  the  tin.  Next  to  this  is  the  light-proof  glass, 
or  porcelain  box,  with  screw-cap  and  paraffined  washer.  The  tube, 
or  box,  should  be  small — holding  two  dr.  to  1/2  oz.  Large  quan- 
tities are  not  admissible,  as  the  ointment  should  be  quickly  renewed. 


Fig.  27. — Method  of  applying  ointment. 

The  ointment  is  applied  by  means  of  the  cotton  swab  wound  on  an 
applicator,  as  described  a  little  further  back,  or  of  a  naked,  smoothly 
rounded  silver  probe.  If  the  swab  is  used,  it  is  first  moistened 
with  boric  acid  solution.  This  keeps  the  cotton  from  taking  up 
too  much  of  the  ointment  and  also  causes  it  to  let  go  easier.  The 
requisite  quantity — say,  a  mass  the  size  of  a  split  pea — is  lifted  from 
the  box,  or  squeezed  from  the  tube,  as  nearly  as  possible  on  the 
very  extremity  of  the  instrument.  The  lower  lid  of  the  patient  is 
depressed  with  the  left  index,  while,  with  the  middle  finger,  the 
upper  lid  is  supported.  The  patient  is  told  to  look  upward,  the 
ointment  is  approached  to  the  eye  with  the  probe  held  in  a  horizontal 
position,  and  parallel  with  the  palpebral  fissure,  the  handle  pointing 


outward;  the  end  holding  the  ointment  is  laid  gently  in  the  lower  cul- 
de-sac,  the  patient's  lids  arc  then  closed,  and  the  probe  withdrawn 
toward  the  temple,  leaving  the  ointment  behind  (see  Fig.  27). 

Caustics. — The  peculiar  chemical  energy  of  these  substances, 
when  brought  in  contact  with  living  tissues,  makes  them  at  once 
either  most  serviceable  or  most  pernicious^ — all  depends  upon  the 
conditions  and  manner  of  contact.  Among  the  more  common 
caustics  used  in  ophthalmic  practice  are  alum,  sulphate  of  copper, 
nitrate  of  silver  and  carbolic  and  chromic  acids.  They  are  em- 
ployed pure  or  in  mitigated  substance,  or  in  aqueous  solution. 
Mitigation  and  solution  both  mean  simply  dilution  to  lessen  the 
severity  of  the  agent.  The  first  is  accomplished  by  mixing  with 
the  caustic  an  inert  powder,  usually  nitrate  of  potash  or  borate 
of  soda;  the  second  by  the  strength  or  percentage  of  the  solution. 
The  pure,  the  mixed,  and  the  mitigated  substances  are  all  to  be 
had  at  the  pharmacists  in  sticks,  or  crayons,  ready  pointed,  fast  in 
holders  and  with  cap  to  cover.  If  the  crayon  needs  sharpening 
this  is  best  done  by  rubbing  it  on  fine  sand-paper,  care  being  taken 
to  keep  do\vn  the  dust;  that  is,  the  rubbing  should  not  be  done  in 
a  draught,  and  the  sand-paper  should  not  be  flirted  about.  Whether 
applied  pure,  mitigated  or  dissolved,  the  touch  to  any  part  of  the 
eye,  particularly  of  the  more  active  caustics,  should  be  by  a  Ime 
point.  For  the  solutions,  the  cotton  brush  on  the  applicator  is 
used.  The  eye  is  bathed  and  sponged,  the  part  to  be  touched  is 
wiped  dry  with  a  bit  of  gauze,  then  the  caustic  is  applied.  As 
the  object  is  to  affect  only  the  diseased  area  the  caustic  must  be 
scrupulously  kept  from  spreading  to  the  healthy  tissues.  If  done 
with  the  crayon,  there  will  be  little  tendency  to  spread  so  long  as  nc 
moisture  comes  in  contact  with  the  spot  treated.  Hence,  in  touch 
ing  any  part  within  the  palpebral  fissure,  it  is  necessary  to  keep 
the  tears  all  away  by  means  of  the  little,  spindle-shaped  cotton 
sponge.  In  order  to  strictly  localize  the  application  when  in 
solution  and  with  the  brush,  it  is  essential  that  there  be  no  super- 
fluous fluid  in  the  brush.  That  is,  there  should  not  be  so  much 
that  when  the  contact  is  made  a  drop  will  be  given  off,  to  run  down 
over  the  healthy  surfaces  and  injure  them.  The  tip  of  the  brush  is 
first  touched  to  a  sponge.  Here,  too,  the  tears  must  be  kept  away, 
just  as  in  using  the  crayon.  The  application  having  been  deemed 
sufficient,  if  within  the  conjunctival  sac,  the  action  of  the  caustic 
is  always  nullified  at  once  by  ])lentiful  douching  either  with  warm 


42 


PARA-OPERATIVE    TECHNIC 


solution  of  boric  acid  or  of  something  that  will  neutralize  chemically, 
as,  of  common  salt,  for  example,  when  the  caustic  is  nitrate  of 
silver.  It  contributes  much  to  the  comfort  of  the  patient  if  a 
drop  of  cocain  solution  is  put  in  just  before  the  application,  and 
another  just  after  the  douching. 

Heat  is  most  grateful  and  beneficial  to  the  eye  in  most  all  of  its 


Fig      28. — Thermaphore. 


inflammations  and  painful  affections.  It  may  be  applied  either 
dry  or  moist.  A  primitive  mode  of  using  dry  heat  is  to  heat  some 
salt  in  a  skillet,  tie  it  up  in  a  woolen  stocking  and  lay  on  the  eye. 
A  more  up-to-date  mctliod  is  by  means  of  hot  water  in  a  rubber 
bag,  but  the  first  will  still  answer  in  a  i)inch.     Yet  other  simi)le 


APPLTCATIOX    or    IIKAT  43 

modes  arc  to  heat  small  ])a(ls  of  cotton  or  wool  in  an  oven  or  Ja])anese 
muff-warmer  or,  best  of  all,  beneath  a  hot  Hat-iron.  Amoni,'  the 
more  scientific  methods  is  that  by  the  llicrninphorc,  illustrated  in 
Fig.  28,  and  that  l^y  the  electric  pad.  'J'he  thermoj)hore  con- 
sists of  a  double  tank  for  the  water.  The  hot  water  Hows  outward 
from  one  tank  through  a  rubber  pipe,  passes  through  a  rubber  coil 
(A),  thence  returns  through  another  tube  to  the  other  tank,  'i'he 
heat  is  supplied  by  a  gas-burner  or  a  s])irit  lam]).  The  one  shown 
in  the  illustration  has  four  sets  of  pipes  and  four  coils,  suitable 
for  both  eyes  of  two  persons,  or  one  eye  each  of  four.  The  coil  is 
wrapped  in  a  small  towel  before  a])i)lying.  In  lieu  of  the  elaljorate 
heating  apparatus  one  may  use  a  jug  of  hot  water,  placed  some- 
what higher  than  the  patient's  head.  From  this  the  water  is 
syphoned  through  tube  and  coil,  and  thence  to  another  jug  on  the 
floor.  The  supply  jug  is  wrapped  in  woolen  cloth  to  retain  the 
heat.  The  electric  pad  consists  of  a  resistance  coil  contained  in  an 
asbestos  envelope,  and  connected  by  insulated  conducting  wires 
with  the  socket  of  an  ordinary  incandescent  lamp.  The  heater  is 
wrapped  in  dry  flannel  before  using.  The  temperature  of  either 
pad  or  coil  must  be  carefully  watched  to  avoid  burning  the  skin. 
If  the  source  of  heat  is  not  continuous  the  application  is  renewed 
every  few  minutes.  The  duration  of  either  procedure  is  from  5  to 
30  minutes.  The  temperature  is  usually  as  high  as  can  be  endured 
or  just  short  of  doing  harm.  Moist  heat  may  be  either  i)lain  or 
antiseptic.  The  simplest  form  of  either  is  that  of  bathing  or 
douching.  To  bathe  the  eye  with  a  hot  liquid  the  i)atient  would 
better  sit  erect,  so  that  there  is  a  minimum  of  blood  in  the  head. 
Stooping  over  would  cause  congestion.  The  water  or  solution 
is  contained  in  a  bowl  or  basin,  held  close  u])  beneath  the  chin, 
and  is  dabbed  on,  over  the  closed  lids,  by  cotton,  gauze,  or  a  ])iece 
of  clean  soft  linen.  The  conjunctival  douche  is  applied  as  already 
directed.  Or  the  applications  may  be  in  the  form  of  fomentations — 
plain  or  antiseptic,  such  as  small  pads  of  cotton  or  wool,  wrung 
out  of  the  very  hot  licjuid,  or  out  of  moderately  hot,  and  further 
heated  under  a  flat-iron.  This  obviates  burning  the  hands  of  the 
attendant.  As  soon  as  the  pad  is  in  place  it  is  covered  with  a  dry 
flannel  cloth  or  other  non-conducting  material.  Of  course,  the 
heat  from  the  rubber  or  the  electric  coil  may  be  made  moist,  plain 
or  antiseptic,  by  keeping  the  wrapping  of  the  coil  wet  with  the  ap- 
propriate liquid. 


44 


PARA-OPERATIVE    TECHNIC 


A  convenient  and  effective  method  of  applying  moist  heat,  often 
employed  by  the  author,  may  be  thus  described:  The  patient  may 
sit  or  lie.  In  either  case  a  catch-basin  is  held,  as  pictured  on  pages 
38  and  39.  A  tuft  of  absorbent  cotton  is  dipped  in  hot  sterile  water, 
or  antiseptic  solution,  and  laid  on  the  closed  eyelids.  It  should  be 
large  enough  to  cover  the  whole  palpebral  region,  and  not  more 
than  1/8  inch  thick  when  wet.  Upon  this  an  attendant  lets  the 
liquid  gently  fall  from  an  eye-dropper.  In  this  way  the  heat  is 
constant,  the  liquid  percolating  through  to  the  skin  without  produc- 
ing any  shock,  the  patient  is  not  disturbed,  as  in  using  applications 
that  need  frequent  renewal,  and  the  attendant  is  spared  the  necessity 


Fig.  29.  Fig.  jo. 

Leitcr's  coils  of  soft  rubber  tubing  for  dry  or  moist  heat  or  cold. 

of  putting  the  hands  into  the  hot  liquid.     Cold  may  l)e  apj)lied  in 
the  same  manner. 

Cold  finds  its  chief  indication  in  severe,  acute  inilammations 
of  the  conjunctiva,  and  immediately  following  injuries  of  the  eye 
or  its  appendages.  Like  heat,  it  is  applied  dry  or  moist.  Dry 
cold  is  most  often  from  cracked  ice,  in  a  rubber  bag,  laid  on  the 
closed  lids.  A  good  plan  is  to  syphon  ice-water  through  a  very 
small  rubber  tube  from  a  large  vessel,  placed  just  a  little  higher 
than  the  patient's  head  through  a  coil  laid  on  the  eye,  thence, 
through  a  still  smaller  tube  to  another  vessel  (Figs.  29  and  30). 
This  has  been  called   mediate  irrigation,  and  may  be  either  dry  or 


INDICATIONS  FOR  HEAT  AND  COLD  45 

moist,  Leiter's  lead  coils  are  too  heavy  for  use  u|)on  the  eye.  Moist 
cold  is  best  transferred  to  the  eye  by  bits  of  old,  heavy  table-linen. 
This  is  more  absorbent  than  new  linen.  One  need  hardly  say  llie 
linen  must  be  aseptic.  Pads  two  to  two  and  one-half  inches  square, 
and  composed  of  several  thicknesses,  are  wrung  out  of  ice-water 
and  laid  on  the  lids.  A  more  convenient  way  is  to  put  a  large 
block  of  ice  into  a  pan  or  basin  and  lay  six  or  eight  of  the  linen 
pads  onto  the  block.  They  are  patted  down  into  good  contact, 
and,  when  one  is  wet  through,  it  is  placed  smoothly  over  the  eye. 
Every  minute  thereafter  the  used  pad  is  put  back  on  the  ice  and 
a  fresh  one  put  on  the  eye.  The  patient  is  apt  to  take  a  sort  of 
grim  pleasure  in  making  the  applications  himself  and  can  be,  with 
impunity,  intrusted  with  the  task.  Indeed,  this  is  true  of  most  of 
the  applications  of  heat  and  cold. 

The  author  has  found  the  following  a  most  convenient  and  highly 
effective  manner  of  applying  moist  heat  or  cold:  The  patient  may 
be  either  seated  or  recumbent.  A  catch-basin  is  so  held  as  to  fit 
snugly  to  the  neck  on  the  side  of  the  affected  eye.  A  moderately 
large  pad  of  absorbent  cotton  is  dipped  into  the  liquid — hot  or  cold — 
that  is  to  be  applied,  then  laid,  without  squeezing,  on  the  closed 
lids.  The  attendant  then  drops  the  liquid  from  an  ordinary  eye- 
dropper  continuously  over  the  pad  of  cotton.  The  cotton  remains 
soft  and  in  perfect  contact  with  the  skin,  the  temperature  is  evenly 
maintained,  the  eye  is  not  shocked  by  too  sudden  sense  of  heat  or 
cold,  the  patient  is  not  disturbed  by  any  changing  of  the  applica- 
tion, nor  of  having  the  eye  hurt  by  an  unguarded  finger-bump,  and 
the  attendant  is  spared  the  discomfort  of  putting  the  hands  into 
the  liquid. 

Madame  Bonsignorio,  p.  200,  in  giving  the  indications  for  heat 
and  cold  in  ocular  therapeutics,  says  that,  generally  speaking,  heat 
is  sedative  and  calming,  but  should  never  be  applied  when  there  is 
much  secretion  present  nor  when  there  is  edema  of  the  conjunctiva. 
She  classes  in  six  categories  the  eye  affections  to  which  heat  and 
cold  are  appropriate: 

1.  In  the  diseases  afrigorc;  iritis,  vernal  catarrh,  Jicat. 

2.  In  other  forms  of  conjunctivitis,  cold. 

3.  In  corneal  infections  with  edema,  especially  in  serpent  ulcer, 
cold. 

4.  In  inflammations  of  the  appendages  of  the  globe,  such  as  phleg- 
mon of  the  orbit,  abscess  of  the  lids,  and  acute  dacrvocvstitis,  cold. 


46  PARA-OPERATIVE    TECHNIC 

5.  In  glaucoma  and  retinal  hemorrhages,  heat,  moderate  and 
prolonged. 

6.  In  the  deeper  inllammations,  where  there  is  no  tendency  to 
suppuration,  like  papillitis,  chorio-retinitis,  cyclitis,  and  iritis,  heat. 

Most  authorities  have  written  that  heat  is  better  applied  for  a 
longer  time  than  is  cold.  With  this  I  do  not  agree,  but  rather  believe 
with  the  minority  that  short  sittings  of  intensely  hot  applications 
have  much  the  same  effect  as  prolonged  ones  of  cold.  Three  to 
five  minutes  of  the  first  will  accomplish  more  good,  however,  than 
one  hour  of  the  second,  or  than  one-half  hour  of  i\v&  first.  Certain 
it  is  that  fomentations  should  not  be  kept  on  for  twenty  and  thirty 
minutes  each,  and  thus  kept  up  for  hours.  The  effect  is  then  much 
like  that  of  a  poultice,  and  this  we  all  know  to  be  bad.  In  general, 
I  prefer  short  sittings  for  the  hot  applications— three  to  ten  minutes, 
as  hot  as  can  be  borne— 115°  to  125°  F.  for  the  moist,  somewhat 
higher  for  the  dry,  and  with  intervals  not  too  short — not  over  four 
to  six  in  twenty-four  hours,  unless  there  is  severe  pain  which  is 
relieved  by  the  heat.  The  intervals  may  then,  in  a  measure,  be 
regulated  by  the  paroxysms  of  pain. 

Massage. — As  it  relates  to  the  surgery  of  the  eye,  this  mode  of 
treatment  is  useful  mainly  in  connection  with  paracentesis  or 
iridectomy  for  glaucoma.  It  is,  however,  a  most  valuable  and 
important  accession  to  ocular  therapeutics  in  general.  Its  principal 
virtue  seems  to  lie  in  the  clearing  and  quickening  eft'ect  it  has  upon 
the  local  lymphatic  and  venous  channels.  Massage  is  plo.in,  or 
medicamentous,  manual  {digital,  rather,  as  concerns  the  eye); 
instrumental,  that  is,  when  an  implement  of  some  sort,  as  a  glass 
rod  or  a  swab,  intervenes  between  the  hand  and  eye;  mechanical, 
as  when  made  by  a  vibratory  machine;  and  electric,  as  when  per- 
formed with  the  electrode  of  a  galvanic  or  other  current.  The 
technic  of  digital  massage  is  given  in  the  chapter  on  paracentesis 
of  the  cornea,  and  that  of  instrumental  in  that  on  the  surgical  treat- 
ment of  trachoma. 

Tissue  Injections. — Among  the  varying  therapeutic  tissue 
injections  practised  in  ophthalmology  are  the  hypodermic,  or 
subcutaneous,  the  intramuscular,  the  suh-conjunctival,  the  sub-tenonian, 
and  the  intraocular.  They  are  all  made  by  means  of  the  ordinary 
hypodermic  syringe.  The  simplest  and  best  form  of  this  instrument 
is  that  in  which  all  is  of  glass  save  the  needle.  The  barrel  has  a 
scale  of  minims  marked  on  its  exterior.     The  inner  surface  of  the 


TISSUE    INJECTIONS  47 

barrel  and  the  outer  surface  of  the  piston  are  ground  so  tliat  they 
fit  exactly  one  upon  the  other.  The  nub  at  the  extremity  of  the 
barrel  is  threaded  to  screw  into  the  needle.  Such  a  syringe  with- 
stands all  standard  means  of  sterilization,  and  may  be  kept  ready 
in  a  strong  antiseptic  solution.  The  needle  is  of  platinum,  is  kept 
scrupulously  sharp,  and  is  sterilized  by  boiling.  The  socket  contains 
a  soft-rubber  washer  to  prevent  leakage.  To  use,  the  Ixirrel  is 
filled  before  the  needle  is  screwed  on,  then,  having  put  the  needle  on, 
the  latter  is  pointed  straight  upward  to  expel  the  air.  Enough  of 
the  liquid  is  then  shot  back  into  the  receptacle  to  bring*  the  i)iston 
to  the  proper  mark  on  the  graduated  scale.  The  hypodermic 
injection  is  administered  by  picking  up  a  fold  of  skin  and  plunging 
the  needle  into  the  fold  coincident  with  its  long  axis,  and  so  as  to 
just  miss  the  tips  of  the  thumb  and  linger  holding  the  fold,  and  the 
fluid  is  forced  slowly  in.  The  plunge  of  the  needle  is  positive 
and  quick — not  hesitating  and  slow.  In  this  way  one  gives  strychnia 
and  other  stimulants  to  overcome  the  evil  effects  of  narcotics  and 
shock  in  the  operating-room,  and  morphin  for  its  quieting  influence 
and  for  the  pain  after  the  operation.  It  matters  little  upon  what 
part  of  the  body  the  fold  of  the  skin  is  chosen.  Having  withdrawn 
the  needle,  the  part  is  gently  massaged  to  favor  quick  absorption. 
It  goes  without  saying  that  for  any  form  of  tissue  injection  the  parts 
involved  are  aseptically  prepared.  In  the  intramuscular  injection 
the  chosen  muscle  is  suddenly  and  deeply  stabbed  with  the  needle, 
avoiding  the  larger  blood-vessels  and  the  underlying  bone.  This  is 
the  kind  usually  employed  for  the  administration  of  solutions  of  the 
mercuric  salts  for  their  constitutional  effects.  For  the  subcon- 
junctival injection  the  eye  is  washed,  douched,  and  cocainized. 
The  lids  are  held  apart  by  an  assistant  with  lingers  or  retractors 
or  by  the  blepharostat.  The  patient  is  directed  to  look  up,  a 
vertical  fold  of  conjunctiva  is  picked  up  with  broad-jawed  fixation 
forceps,  just  below  the  cornea.  The  needle  is  passed  into  the  lower 
half  of  the  fold,  tangential  to,  but  not  hugging,  the  globe,  and  pointing 
somewhat  downward.  The  contents  of  the  syringe,  usually  some 
lo  or  12  minims  of  solution,  are  then  exhausted,  causing  a  large 
bleb  of  conjunctiva  to  rise.  The  syringe  is  withdrawn,  the  lids 
carefully  closed  over  the  bleb,  and  the  eye  bandaged.  This  is  the 
form  employed  in  the  less  virulent  infections  of  the  globe  after  opera- 
tions, for  the  local  eft"ects  of  mild  antiseptics,  like  weak  salt  solutions 
and  mercuric  solutions.     The  most  all-round  satisfactorv  solution 


48  PARA-OPERATIVE    TECHNIC 

in  mild  cases  is  the  physiologic  salt.  It  is  followed  by  little  distur- 
bance when  used  alone,  and  is  not  so  painful  nor  so  apt  to  result  in 
small  round-cell  infiltration  of  the  conjunctiva  as  are  the  stronger 
salt  solutions.  None  but  chemically  pure  salt  is  admissible.  They 
are  specially  useful  in  the  treatment  of  the  lingering  forms  of 
uveitis  following  certain  extractions,  and  certain  iridectomies  for 
chronic  irritative  glaucoma,  particularly  those  characterized  by 
recrudescences.  The  subtenonian  injection  is,  as  its  name  implies, 
into  Tenon's  capsule.  Another  name  is  intracapsular  injection. 
It  is  one  of  the  sheet  anchors  in  the  treatment  of  severe  septic  infection 
threatening  panophthalmitis.  The  eye  is  prepared  and  the  lids 
held  apart  as  for  the  subconjunctival  injection.  Cocain,  however, 
often  has  little  effect,  owing  to  the  hyperemia  and  inflammation 
that  are  apt  to  be  present,  so  that  it  is  advisable  in  cases  of  very 
sore  eyes  and  demoralized  patients  to  narcotize  with  nitrous  oxid. 
The  bottom  of  the  external  conjunctival  cul-de-sac  is  seized  with 
strong  fixation  forceps  in  such  a  way  as  to  include  a  fold  of  the 
outer  check  ligament,  the  eye  being  meanwhile  in  adduction. 
This  is  drawn  forward  (upward,  one  might  better  say)  and  the 
needle  passed  backward,  deep  into  Tenon's  capsule,  following  the 
sheath  of  the  external  rectus.  The  regulation  dose  with  us  consists 
of  12  minims  of  i%  salt  solution  in  which  are  dissolved  i/ioo  gr. 
of  mercuric  cyanid  and  1/25  gr.  of  dionin.  A  small  dose  of  acoin 
or  morphin  is  sometimes  added  to  alleviate  the  suft'ering  that  is 
almost  inevitable  afterward.  Dionin  has  come  to  be  regarded  as 
an  almost  necessary  ingredient  of  the  last  two  forms  of  tissue  injec- 
tions. It  adds  greatly  to  the  local  disturbance  which  ensues.  In 
fact,  the  reaction  is  often  so  great,  and  of  such  a  character,  as  to 
be  positively  scarey,  especially  to  a  novice.  Fortunately,  the 
benefit  is,  as  a  rule,  commensurate  with  the  reaction,  and  the  latter 
is,  therefore,  welcomed.  A  subsequent  injection  is  not  given  until 
the  visible  results  of  the  previous  one  have  passed  away,  except  in 
desperate  cases.  Between  mildly  reacting  injections  2  days,  and 
between  the  severer  ones  four  to  six  days,  is  about  the  average 
time — but  if  speedy  loss  of  the  eye  is  threatened,  they  may  be  given 
daily.  If  the  pain  during  the  reactive  stage  be  great,  fomentations 
as  hot  as  can  be  borne,  are  applied  to  the  closed  lid,  and  hot  douches 
to  the  conjunctival  sac.  The  therapeutic  value  of  these  subcon- 
junctival and  intracapsular  injections  is  due,  in  all  probability, 
to   several  causes — partly   to   osmosis,    partly   to   local   antisepsis, 


BLOOD-LETTING  49 

and  largely  to  local  counter-irritation,  and,  when  dionin  is  ])rcscnt, 
also  largely  to  their  lymphagogue  properties.  Intraocular  injections 
are  such  as  are  employed  in  artificial  ripening  of  cataract — into 
the  lens  substance — and,  in  detachment  of  the  retina — into  the 
vitreous  or  beneath  the  retina.  They  cannot  be  called  true  and 
tried  measures  and  have  no  real  place  here. 

Blood-letting. — This  venerable  tliera])cutic  measure  seems 
now  to  hold  a  higher  place  in  ophthalmology  than  in  any  other 
department  of  medicine.  This  is  true,  at  least,  of  local  or  topic 
blood-letting.  General  blood-letting,  or  venesection,  is  now  often 
resorted  to  in  the  treatment  of  the  eye,  and  it  is  regaining  some  of 
its  ancient  prestige  at  the  hands  of  the  internists.  It  is  especially 
valuable  for  lowering  high  blood-pressure  before  operations  for 
cataract  and  glaucoma.  Other  names  for  the  last  mentioned  are 
phlebotomy  and  artcriotomy,  as  indicating  whether  a  vein  or  an 
artery  is  opened. 

The  effects  of  a  general  blood-letting  (a  moderate  bleed,  say  from 
eight  to  ten  ounces)  are  seen  in  a  diminution  of  the  blood  pressure, 
though  not  for  long,  and  on  the  pulse  which  undergoes  temporary 
acceleration.  In  feverish  patients  the  temperature  falls  and  breath- 
ing is  calmer  but  these  effects  arc  fugitive.  The  number  of  red 
corpuscles  is  reduced  after  blood-letting  and  then  slowly  returns  to 
normal.  Blood-letting  is  formally  contra-indicated:  in  the  young,  in 
old  age,  in  cahexia  from  any  cause,  in  anaemia  and  convalescence. 
With  regard  to  the  hour  for  blood-letting,  avoid  the  digestive  period 
because  it  might  cause  vomiting. 

As  to  quantity  it  is  not  customary  to  exceed  ten  fluid  ounces.  A 
pint  is  a  maximum  rarely  reached,  nevertheless  in  strong  robust 
subjects  the  process  may  be  repeated  in  from  24  to  36  hours.  Bleed- 
ing may  be  depletive  or  depurative. 

The  Operation  of  Venesection  or  Phlebotomy. — The  patient 
should  be  seated  in  a  chair  or  in  bed,  rather  than  recumbent,  es- 
pecially where  marked  effects  are  desired,  as  the  more  rapidly 
the  blood  is  abstracted  the  less  will  be  required  to  lower  the  force 
of  the  circulation.  Standing  might  induce  syncope  prematurely, 
while  the  prone  position  might  allow  too  great  an  abstraction  of 
blood  before  syncope,  which  is  Nature's  danger  signal,  had  been 
produced. 

Septic  phlebitis  is  the  most  serious  complication  to  be  feared 
after  phlebotomy,  and  should  be  guarded  against  by  rigid  asepsis. 
4 


50 


PARA-OPERATIVE    TECHNIC 


The  hands  of  the  operator,  the  instruments,  and  the  field  of  opera- 
tion having  been  rendered  thoroughly  aseptic,  a  bandage  or  cord 
is  tied  about  the  middle  of  the  upper  arm,  with  moderate  firmness, 
o  as  to  arrest  the  venous  flow  without  interfering  with  the  arterial. 
Grasping  a  stick,  or  roll  of  bandage,  or  merely  closing  the  hand 
tightly  will  then  cause  the  veins  to  become  prominent  (Fig.  31). 
The  median  basilic  is  now  fixed  by  pressure  of  the  left  thumb,  and, 
with  a  sharp  cataract  knife  or  bistoury  the  vein  is  opened  (not 
divided)  obliquely  to  its  long  axis  at  about 
its  middle  point.  The  middle  portion  of 
the  vein  is  chosen  as  being  farthest  removed 
from  the  brachial  artery  on  the  outer  side 
and  also  from  the  internal  cutaneous  nerve 
on  the  inner  side.  The  first  is  separated 
from  the  basilic  vein  only  by  the  semilunar 
fascia  of  the  biceps  tendon  and  may  be 
located  by  its  pulsation,  and  the  second  lies 
on  top  of  the  vein,  just  where  it  joins 
the  common  ulnar  vein.  Blood  will  pro- 
bably flow  from  the  wound  in  a  full 
stream;  but  if  it  does  not,  bleeding  may 
be  promoted  by  alternately  opening  and 
closing  the  hand.  The  blood  should  be 
collected  in  a  graduated  bowl,  so  as  to 
estimate  the  amount  withdrawn.  Ten  to 
twenty  ounces  will  be  necessary.  It  is  best 
to  have  a  sphygmomanometer  attached 
to  the  opposite  arm  so  as  to  measure  the 
blood-pressure  from  minute  to  minute. 
The  pulse  will  also  indicate  when  the  req- 
uisite eft"ect  has  been  produced.  When 
this  is  accomplished  apply  a  dry  aseptic 
compress,  and  secure  this  by  a  figure-of-8 
bandage  around  the  elbow,  and  place  the  arm  at  rest  until  the 
wound  is  healed.  Occasionally  neuralgic  pain  is  caused  by  the 
implication  of  some  of  the  fibres  of  the  internal  cutaneous  nerve  in 
the  cicatrix. 

Local  blood-letting,  as  practised  by  the  eye  specialist,  consists 
in  extracting  quantities  of  blood,  varying  in  amount  from  1/2  oz. 
to  2  oz.,  from  a  limited  area  external  to  the  outer  canthus  by  means 


I,  Opening 
basilic  vein, 
cephalic  vein, 
vein.  4,  Basilic  vein.  5, 
Internal  cutaneous  nerve. 
6,  Brachial  artery.  Only 
the  semilunar  fascia  of  the 
biceps  separates  median 
basilic  vein  from  brachial 
artery. 


ARTIFICIAI.    I.i;i:(  II  51 

of  leeching  The  leech  may  ])e  natural  or  arliticial.  The  best 
natural  leech  is  tlie  Scan(lina\  ian  \aritiy,  which  is  lo  be  had  in 
most  of  the  larger  pharmacies.  Each  one  is  ca|)able  of  drawing 
nearly  1/2  ounce  of  blood  before  becoming  gorged  and  letting  go. 
Two  of  them  are  suflicient,  for  if  it  is  desirable  to  abstract  more 
than  I  oz.  one  may  increase  the  quantity  to  the  proper  measure 
by  encouraging  the  aflcr-blrcdiiii^.  This  will,  in  many  instances, 
continue  till  made  to  slop,  which  is  easily  accomplished  by  holding 
a  tiny  bit  of  absorbent  cotton  tightly  on  the  bite  with  the  linger. 
The  bleeding  having  ceased,  the  cotton  is  left  sticking  to  the  spot. 
Preparatory  to  either  mode  of  leeching,  the  temple  is  rendered 
aseptic.  Unfortunately,  the  natural  leech  cannot  be  sterilized, 
but,  fortunately,  it  is  naturally  a  cleanly  thing,  even  if  it  does  live 
in  mud.  The  most  suitable  j)lace  to  aj)])ly  the  leech,  either  living 
or  artificial,  is  that  which  is  on  a  lexel  vrilh  the  outer  canthus, 
and  just  external  to  the  outer  rim  of  the  orbit.  When  two  or 
more  leeches  are  applied    their  heads  are    ])laced   close  together 


I 


r^iG.  S2. — .\ruficial  IfC'ch. 


and  in  a  horizontal  line.  One  who  is  ex])erienced  in  applying  the 
leech  can  guide  the  animal's  head  accurately  to  the  point  selected  for 
the  bite  by  holding  its  body  in  the  folds  of  a  na])kin.  The  tyro 
would  better  use  a  leech-tube.  Into  this  the  leech  is  dropped, 
big  end  lirst.  The  mouth  is  in  the  small  end  that  is  forever  reach- 
ing out.  If  the  leech  does  not  take  hold  readily,  lightly  scraping 
off  the  epidermis  with  a  scalpel  or  putting  a  drop  of  milk  on  at 
the  spot  will  induce  it  to  do  so.  Having  once  begun. to  draw 
blood,  it  is  allowed  to  remain  attached  till  it  falls  off.  The  used, 
or  "stripped"  leech  is  never  so  good  as  a  fresh  one.  There  are 
several  kinds  of  artificial  leeches.  The  one  bearing  the  name  of 
Baron  Heurteloup  is  still  the  favorite.  Recently  the  elaborate  scari- 
fier that  formerly  went  with  it  has  been  omitted.  The  leech  is 
shown  in  Fig.  ;^2.  It  consists  of  a  metallic  ])iston  with  asbestos 
packed  head  fitting  \erv  tiglitly  in  a  ghiss  cylinder  and  worked  by 


52  PARA-OPERATIVE    TECHNIC 

a  ihumb-scrcw.  The  skin  is  scarified  at  the  point  indicated  for 
the  leech-bite,  the  free  end  of  the  cyHnder  is  moistened,  applied  to 
the  part,  and  the  air  gradually  exhausted  by  turning  the  screw.  The 
relief  and  the  improvement  that  result  from  leeching  are  often  re- 
markable, though  not  usually  immediate;  from  6  to  24  hours  may 
elapse  before  the  benefits  are  apparent.  It  is  difficult,  therefore,  to 
conceive  of  the  modus  operandi.  Can  it  be  the  mere  topic  depletion 
whereby  the  pain  is  relieved  by  freeing  the  sensory  end-bodies  from 
pressure,  and  the  inflammation  reduced  through  quickening  the 
circulation  in  the  blood  and  lymph  channels  by  the  ensuing  relax- 
ation? Hardly.  The  natural  leech  seems  to  be  more  effective 
than  the  artificial,  and  for  this  reason  I  have  sometimes  wondered 
if  it  were  not  because  of  its  more  potent  psychic  effect. 


CHAPTER   II. 
INSTRUMENTS  AND  THEIR  MANAGEMENT. 

"lis  doivent  etre,  pour  le  praticien,  des  objets  sacro-saints;  des  objcts 
auxquels  il  ne  laisse  toucher  personne  de  profane,  qu'il  considere  lui-meme 
avec  amour  a  cause  de  leur  perfection,  avec  respect  a  cause  de  leur  desti- 
nation. II  apportera  le  plus  grand  soin,  non  seulement  a  leur  choix, 
mais  aussi  a  leur  enireiien" — Landolt. 

"They  should  be  for  the  practitioner,  objects  almost  sacred; 
objects  not  to  be  profaned  by  vulgar  hands — that  he  regards  with 
fondness  because  of  their  perfection,  and  with  respect  because  of 
their  destination.  He  will  exercise  the  utmost  care  not  only  in 
their  selection,  but  also  in  their  maintenance." 

Thus  wrote  my  friend  and  teacher,  nearly  30  years  ago,  in  a 
little  work  called  "A  Box  of  Instruments^  While  with  him,  he 
commissioned  me  to  translate  it  for  publication  in  this  country. 
I  sent  the  English  version  to  a  friend  in  New  York  who  consigned 
it  to  oblivion  as  concerned  the  ophthalmic  world,  by  turning  it 
over  to  a  journal  for  general  medicine.  It  was  deserving  of  a  better 
fate — by  reason  of  its  subject  matter.  This,  then,  would  seem 
a  fitting  time  and  place  to  revive  some  of  the  excellent  precepts 
and  principles  embodied  in  that  book,  and  to  add  thereto  whatever 
seems  appropriate,  in  order  to  bring  the  subject  abreast  of  the  time. 

The  word  management  in  the  above  caption  refers  to  both  the 
manipulation  and  the  care  of  instruments. 

First,  as  to  the  instruments  themselves:  What  are  the  qualities 
requisite  and  desirable  in  them  ?  This  is  a  broad  question  and  one 
of  many  sides.  I  shall  attempt  to  answer  it,  not  assuming  the  r61e 
of  an  oracle,  but  as  one  who  has  taken  an  active  interest  in  the  mat- 
ter, both  practical  and  theoretical,  for  the  past  two  and  one-half 
decades.  Much  has  been  written  concerning  the  instruments  of  the 
"Vienna  School,"  of  the  "Parisian  School,"  of  the  "Berlin  School," 
and  of  the  "London  School,"  but  little  concerning  the  ''American 
School";  therefore,  an  effort  will  be  made  to  show  also  something  of 
what  our  countrymen  have  done  in  the  line  of  surgical  instruments 
for  the  eye  specialist.  Of  the  myriad  instruments  that  have  been 
conceived  as  applicable  to  ocular  surgery,  the  vast  majority  have 

53 


54  INSTRUMENTS    AND    THEIR    MANAGEMENT 

not  stood  the  test  of  time;  and  it  is,  after  all,  remarkable  how  few 
really  are  necessary  or  desirable.  Every  surgeon  and  every  maker 
of  surgical  instruments,  even  down  to  every  salesman,  has  his 
own  ideas  on  that  point.  The  writer  has  great  respect  for  the  pecu- 
liar notions  of  others,  especially,  in  this  instance,  if  they  be  those 
of  a  confrere.  So  long  as  his  work  comes  up  to  the  standard,  no 
matter  how  peculiar  his  notions,  all  honor  to  him.  But  his  imple- 
ments may  not  be  above  criticism.  As  to  the  maker,  he  is  prone  to 
regard  the  matter  solely  from  a  mechanical  standpoint,  without 
taking  into  consideration  the  human  element  that  figures  so  largely 
in  the  material  upon  which  the  instruments  in  question  are  employed. 
With  regard  to  the  salesman — well,  his  business  is  to  sell;  and  as 
a  proof  that  he  fully  understands  it,  witness  the  manner  in  which 
he  beguiles  the  artless  and  aspiring  tyro  into  stocking  himself  up 
with  a  lot  of  articles  he  will  never  use. 

The  first  great  requisite  in  any  mechanical  contrivance  is  efficiency, 
but  the  maximum  of  efficiency  should  be  attained  along  with  the 
maximum  of  simplicity.  And  surgical  instruments  are,  perhaps, 
peculiar  in  demanding  the  most  rigid  enforcement  of  this  law. 
These  are  the  key-notes.  Close  after  them  come  such  other  at- 
tributes as  grace  of  outline,  delicacy  of  parts,  and  elegance  of  finish. 
They  should  be  simple  in  the  sense  of  being  uncomplicated,  as  also 
in  that  of  being  plain.  These  properties  are  conducive  to  both 
cleanliness  and  dexterity — hence,  to  safety  and  success.  They 
should  be  as  light  as  is  consistent  with  adequate  strength,  which  is 
also  an  advantage  in  their  use;  hence,  the  need  of  delicacy  of  parts. 
And  they  should  be  pleasing  to  the  eye — of  their  possessor,  at  least. 
This  were  argument  enough  for  the  grace  of  outline  and  the  elegance 
of  finish;  but  there  are  decidedly  practical  reasons  also.  One  is 
actually  capable  of  better  effort  when  there  is  present  a  conscious 
pride  in  his  means;  again,  the  smoother  and  truer  and  brighter 
the  surface,  the  easier  to  maintain,  therefore,  the  demand  for 
attractiveness. 

Another  most  excellent  tiling  in  connection  with  the  operative 
equipment — especially  of  the  oculist — is  a  certain  uniformity,  or 
harmony,  of  the  corresponding  ])arts  of  the  different  articles.  In 
the  form  and  size  of  tlie  liandles,  for  example,  as  also  in  the  size 
of  scissors  rings,  the  length  of  scissors  branches,  and  in  the  angle 
at  which  the  blades  of  keratomes  are  set.  To  be  sure,  this  cannot 
be  carried  out  to  the  letter,  on  account  of  the  inevitably  great  dif- 


HANDLES  55 

ference  in  bulk.  But  most  of  the  smaller  instruments  in  daily  use 
can  be  made  to  conform  to  this  principle.  There  are  undeniable 
advantages  in  the  habitual  feel  of  the  instrument  imparted  to  the 
fingers  in  this  way,  not  to  speak  of  those  as  to  appearances,  that 
such  a  collection  would  enjoy,  over  a  heterogeneous  assortment. 
Among  the  most  obvious  essentials  in  all  instruments  is  superiority 
of  material.  This  is  especially  true  of  the  cutting  instruments. 
Unfortunately,  this  is  a  quality  of  which  it  is  difficult  to  judge 
beforehand.  A  few  years  ago  all  of  our  finer  steel  instruments  were 
made  in  Europe,  and  the  names  of  Collin,  Liier,  Richter,  Windier, 
Weiss,  and  a  few  others  were  not  merely  guarantees  of  high  quality, 
as  they  are  still,  but  they  were  the  and  the  only  ones.  Nowadays 
good  and  bad  instruments  are  made  "all  over,"  and  one  must  take 
his  chances.  Certainly  the  best  of  those  turned  out  in  the  United 
States  are  second  to  none. 

Thus,  in  a  general  way,  is  answered  the  question  as  to  what  are 
the  qualities  requisite  and  desirable  in  a  surgical  instrument.  And 
what  is  true  of  these  as  a  whole  is  true  of  those  pertaining  to  any 
branch.     Now,  to  particularize. 

Following  Landolt's  classification  we  shall  begin  with  the  instru- 
ments with  handles.  "And  'n  passing,  let  us  bestow  a  word  upon 
this  feature  of  the  instrument — a  feature  of  greater  importance 
than  many  seem  to  think.  Is  it  not  the  intermediary  between  the 
hand  that  guides  and  the  part  that  engages?  Is  it  not  through 
it  that  the  sensitive  fingers  of  the  operator  are  made  aware  of  the 
resistance  their  movements  encounter;  these  fingers  which  put  in 
touch  with  the  work  the  reason  that  contrives,  the  intellect  that 
seeks,  and  the  power  that  executes?"^  The  handle  was  formerly 
made  of  ivory  or  bone,  but  these  materials  have  now,  quite  properly, 
yet  reluctantly,  been  discarded  for  metal,  such  as  aluminum,  to 
admit  of  boiling.  Yet  ivory  is  an  ideal  material.  Its  weight  is 
just  right.  It  is  a  poor  conductor  of  heat  and  cold,  and  its  best 
quality  is  a  peculiar  adhesiveness.  "Clings  to  the  fingers,"  as 
Landolt  says.  Their  rectangular,  or  rather,  octagonal  form  has, 
with  equal  propriety,  been  retained.  The  classic  form  is  that  of  a 
slightly  fusiform,  quadrilateral  beam  with  chamfered  edges.  The 
heaviest  part  of  the  beam  is  at  the  junction  of  the  first  and  middle 
thirds,  where,  in  cross  section,  it  measures  4.5x6  mm.  From  here 
it  gradually  tapers  to  either  extremity,  where  the  cross  sections  each 

^  Passages  in  quotation  marks  are  Landolt's. 


DESCRIPTION  OF  PLATE  I. 


1.  Arlt  scalpel,  medium. 

2.  Arlt  scalpel,  large. 

3.  Beard  scalpel,  extra  convex. 

4.  Beard  scalpel. 

5.  Sharp  straight  bistoury. 

6.  Blunt  curved  bistoury. 

7.  Beer  (or  Barth)  knife. 

8.  Weber  lacrimal  knife,  straight. 

9.  Weber  lacrimal  knife,  curved. 

10.  Agnew  lacrimal  knife. 

11.  Graefe  knife. 

12.  Bent  lance  keratome,  small. 

13.  Bent  lance  keratome,  large. 

14.  Bent  lance  keratome,  medium. 

15.  Neuter  cystotome. 

16.  Graefe  cystotome. 

17.  Knapp  cystotome. 

18.  Beard  cystotome. 

19.  Pagenstecher  knife  needle. 

20.  Knapp  knife  needle. 

21.  Beard  blunt  dissector 


S6 


PLATK 


SCALPELS  59 

represent  a  rectangle  whose  sides  are  3x4  mm.  for  the  free  end  and 
3.5x4.5  mm.  for  the  other — not  allowing,  of  course,  for  the  chamfer. 
The  regulation  length  is  about  10.5  centimeters.  This  size  and  shape 
are  common,  or  should  be  so,  to  knives,  including  lances  to  needles, 
knife-needles,  cystotomes,  hooks,  curets,  wire-loops,  spatulas, 
spoons,  spuds,  and  retractors.  There  are  several  reasons  for  its 
existence:  First,  it  is  handy  to  hold  and  to  manipulate,  adapting 
itself  nicely  to  the  pulps  of  the  fingers.  Second  as  all  the  working 
parts  arc  attached  with  their  flats  in  the  same  plane  as  the  greater 
transverse  diameter  of  the  handle,  one  feels,  in  turning  the  handle 
on  its  long  axis,  just  how  much  rotation  he  has  imparted  to  the 
instrument.  This  is  of  the  greatest  value  in  such  acts  as  the  making 
of  the  corneal  section,  and  in  the  cystotomy  of  a  cataract  operation. 
One  can  always  know  the  position  of  the  blade  or  other  implement 
by  noting  that  of  the  greater  width  of  the  handle.  The  edge  of 
the  blade  or  the  point  of  a  hook  moves  in  the  sense  of  the  greater 
width.  Moreover,  the  name  of  the  maker  is  supposed  to  be  stamped 
on  the  side  o  the  handle  that  corresponds  to  the  back  of  the  instru- 
ment, so  that,  unless  it  be  a  blade  with  double  edge,  an  additional, 
and  often  serviceable,  sign  is  given.  Landolt  suggested  that,  while 
none  of  these  instruments  should  have  round  handles,  the  sides  should 
be  equal  (square  in  cross  section)  on  instruments  one  of  whose 
offices  is  to  rotate  in  working,  such  as  cystotomes  and  needles. 
It  is  just  as  essential  to  know  the  position  and  direction  of  the  blade 
of  a  cystotome  as  that  of  a  knife.  It  often  disappears  behind  the 
iris,  but  one  can  be  absolutely  guided  by  the  two  lateral  dimensions 
of  the  handle,  in  applying  the  point  to  the  capsule,  and  in  giving 
those  two  quarter  turns  that  are  such  an  important  part  of  the  cap- 
sulotomy.  The  little  difference  in  the  two  opposite  sides  does  not 
interfere  with  rotation.  Then,  as  to  the  needle,  it,  too,  has  its 
blade — a  double-edged  one.  It  is  the  proper  thing  to  withdraw 
it  from  the  anterior  chamber,  for  instance,  in  the  same  sense  that 
it  entered;  but,  with  the  blade  hidden  in  an  opaque  lens,  as  is  often 
the  case,  and  the  aqueous  most  likely  evacuated,  this  would  not  be 
so  easy  if  there  were  not  the  handle  to  point  the  way. 

So  much  for  the  handles.  Next,  for  the  instruments  which  they 
carry,  together  with  a  few  notes  as  to  their  manipulation.  Let  us 
begin  with  the 

Scalpels. — Of  these  there  should  be  at  least  two — one  after  \'on 
Arlt's  model  and  another  with  a  blade  of  sreat  convexitv.     Arlt's 


6o  INSTRUMENTS    AND    THEIR    MANAGEMENT 

is  excellent  for  use  in  many  ways,  yet  the  other,  while  just  as  good 
for  all  around  work,  is  superior  under  certain  special  conditions. 
The  knife  in  question  is  one  devised  by  the  writer  about  fifteen 
years  ago,  though  the  latest  modification  of  it  has  even  greater  con- 
vexity of  edge.  (Plate  I,  Fig.  3.)  Orignially  intended  mainly  for 
use  in  blepharoplasty,  it  has  become  my  chosen  knife  in  most  in- 
stances where  a  scalpel  is  needed.  It  owes  its  individuality  and  its 
value  to  the  extraordinary  convexity  of  that  part  of  the  edge  which 
is  situated  near  the  extremity  of  the  blade.  The  length  of  the  latter 
is  about  2.5  centimeters,  and  its  width,  at  the  broadest  part,  7  to  8 
mm.,  while  Arlt's  is  3  to  3.5  centimeters  long,  and  its  greatest  wddth 
is  5  to  6  mm.  With  the  ordinary  scalpel,  held  pen-holder  fashion, 
according  to  rule,  and  with  incisions  of  average  penetration,  the 
extent  to  which  the  edge  engages  the  tissues  is  very  slight,  being 
limited  to  the  point  and  several  contiguous  millimeters.  Even 
with  the  handle  as  near  as  possible  to  the  horizontal  as  is  consistent 
with  this  manner  of  holding  the  handle,  the  length  of  available 
edge  is  less  than  one-fourth  of  the  whole.  Therefore,  as  regards 
the  cutting  quahties  of  any  but  the  terminal  third  of  the  blade,  it 
were  as  well  that  they  did  not  exist.  It  is  desirable,  then,  that  the 
trenchancy  of  the  part  concerned  be  heightened  in  the  utmost. 
This  is  precisely  what  is  aimed  at  in  this  scalpel.  A  single  point, 
like  that  of  the  bistoury  or  the  Beer's  knife,  is  insufficient,  for  the 
reason  that  it  soon  loses  its  keenness;  whereas,  the  extended  con- 
tact unavoidable  with  an  edge  of  low  convexity,  is  yet  more  unfitting, 
because  it  is  less  guidable  and  requires  more  force  on  account 
of  the  friction.  The  special  configuration  of  the  blade  under 
consideration  offers  an  efficient  mean  between  the  two  extremes. 
If  held  fiddle-bow  fashion,  as  would  seem  to  be  the  preferable 
for  its  use  in  general,  its  incisive  qualities  are  truly  remarkable. 
It  has  the  added  property  of  being  able  to  cut  nearly  as  well  in 
pushing  as  in  pulling— 2i  veritable  fiddle-bow  action.  With  it  such 
measures  as  the  Streatiield  counter-grooving  of  the  tarsus,  the 
intermarginal  incision  to  receive  the  graft  in  restoration  of  the  free 
border  of  the  lid,  etc.,  arc  particularly  facilitated.  The  custom 
of  making  the  free  extremity  of  the  handle  into  a  blunt  dissector 
or  of  making  "double-header"  instruments  of  any  description  is 
to  be  decried  as  not  in  keeping  with  advanced  ideas.  Besides, 
there  is  little  to  l)e  gained  in  time  or  convenience  by  their  use. 
Who  has  not  seen  in  the  well-known  Daviel's  spoon  combination 


KNWES  ,  6 1 

the  persistence  with  which  the  cyslolome  member  tried  to  get 
caught  into  things  while  the  spoon  member  was  occupied?  The 
very  diminutive  scalpels  often  seen  may  have  a  place  in  ophthalmic 
surgery;  if  so,  the  writer  has  never  found  it. 

Bistouries.— Two  of  these  also.  One  having  a  long,  straight- 
edged  blade,  with  good,  stiff  back,  joined  to  the  handle  by  a  strong 
shank,  for  work  such  as  deeply  thrust  incisions  for  orbital  cellulitis. 
The  blade  should  be  at  least  4  centimeters  in  length,  and  1/2 
centimeter  wide  at  the  hilt,  gradually  tapering,  by  the  back,  in  a 
slight  curve  to  the  point.  The  other  smaller,  wnth  blade  curved, 
concave  on  the  edge,  and  extremity  neatly  blunted.  Its  length 
should  not  exceed  3  centimeters,  and  its  greatest  breadth,  which 
is  also  at  the  base,  scant  3  mm.  This  has  been  called  a  probe- 
pointed  bistoury,  and  is  most  useful  in  enlarging  openings,  or 
fistulous  tracks,  into  suppurating  cavities,  or  leading  to  foreign 
bodies  in  the  orbit,  etc.  It  would  also  answer,  in  a  pinch,  for 
extending  an  inadequate  corneal  section  in  extraction. 

Beer's  Knife. — One  of  these  is  sufficient,  and  it  should  be  of  the 
true  Beer,  or,  rather,  Barth,  pattern,  i.e.,  not  of  convex  edge,  like 
the  old  Beranger  cataract  knife,  but  straight  both  edge  and  back, 
and  somewhat  smaller  in  all  dimensions  than  that  of  Beer.  Three 
centimeters  long  and  8  mm.  at  the  widest  point  is  ample,  w^hereas 
the  original  w^as  4  centimeters  long  by  i  centimeter  for  the  rise  of 
the  hypotenuse.  Although  no  longer  employed  in  the  capacity 
for  which  it  was  intended,  yet  for  the  incision  of  hordeola,  and  of 
chalazions  by  the  Agnew  method,  through  the  border  of  the  lid, 
there  is  no  knife  its  equal. 

Lacrimal  Knife. — Owing  to  the  few  occasions,  these  latter  days, 
for  Bowman's  operation,  a  single  representative  of  this  class  is 
enough;  and  my  choice  would  be  for  that  of  Agnew.  The  blade, 
including  the  probe,  is  i  1/2  centimeters,  of  which  the  probe  and  its 
neck  comprise  a  trifle  more  than  one  mm.  The  back  has  a  slight 
convexity,  and  the  edge  a  more  decided  one.  The  greatest  width 
is  at  the  middle,  where  it  measures  2  mm.,  and  it  is  connected  with 
the  handle  by  a  round,  malleable  iron  shank,  about  31/2  centi- 
meters long.  The  object  and  advantages  of  this  last  feature,  in 
adapting  the  knife  to  the  overhanging  brow  and  permitting  of  its 
entrance  into  the  nasal  duct,  are  too  well  known  to  dwell  upon. 
The  Weber  knife  is  lacking  here,  and  the  neck  of  its  probe,  being 
too  long  and  curved,  renders  it  liable  to  snap  off  in  the  tissues. 


62  IMSTRUMENTS    AND    THEIR    MANAGEMENT 

Graefe  Knives. — One  could  manage  to  get  on  with  three  cataract 
knives,  provided  he  were  within  convenient  distance  of  a  reputable 
instrument  maker  or  repair  shop,  but  from  four  to  six  would  not  be 
considered  an  excessive  number.  Graefe  knives,  in  common  with 
all  keratomes,  are  the  most  exacting  of  all  the  ocular  instruments 
as  to  their  keeping.  This  is  especially  true  of  the  point.  No 
matter  how  faultless  the  edge,  if  the  point  is  not  perfect  the  instru- 
ment, for  the  moment,  is  worthless.  So  exceedingly  delicate  is  it 
that  the  merest  touch  against  the  box  in  which  it  is  kept,  or  against 
the  tray  or  dish  in  which  it  is  cleansed,  or  against  the  towel  in 
wiping  it,  and  it  is  out  of  service.  For  these  reasons  it  is  advisable 
to  have  a  reserve  supply,  and,  in  preparing  for  an  extraction  or 
iridectomy,  to  make  ready  two  such  knives  lest  one  should  come 
to  grief.  The  blade  of  the  most  approved  model  is  30  to  32  mm. 
long,  full,  strong,  2  mm.  wide  at  its  base,  where  it  joins  the  shank; 
at  this  point  also  it  is  full  1/2  mm.  thick,  and  from  here  both  width 
and  thickness  decrease  by  insensible  degrees  toward  the  extremity, 
till,  within  4  or  5  mm.  of  it  the  width  is  reduced  to  less  than  i  i  /  2  mm. 
From  here  the  lines  converge,  in  a  slight  curve,  to  form  the  point. 
An  error,  often  found  in  connection  with  the  Graefe  knife,  is  that 
the  more  pronounced  narrowing  of  the  blade  begins  too  far  back, 
and  that,  instead  of  the  opposite  sides  approaching  in  the  correct 
outward  sweep,  they  do  so  in  straight  lines.  This  makes  a  long, 
needle-like  point,  that  is  extremely  frail  and  difficult  to  keep  in 
order.  On  the  other  hand,  too  abrupt  a  termination,  while  not  so 
objectionable  as  the  kind  just  described,  is  also  objectionable  in 
that  it  lacks  penetrating  equalities.  These  defects  are  more  apt  to 
be  acquired  at  the  hands  of  unskilled  repairers  than  to  be  present 
in  the  new  instrument.  The  back  is  scrupulously  rounded.  Blade 
and  handle  are  connected  by  a  pedestal-shaped  shank  fully  1/2 
centimeter  long,  which  must  be  strong  and  firm. 

Lance  Keratomes. — It  would  be  well  to  have  not  less  than  four, 
say  two  with  blades  of  average  dimensions,  the  third  of  somewhat 
larger,  and  the  fourth  of  smaller  measurement.  This  knife  is 
usually  referred  to  as  the  keratome,  and,  although  strictly  speaking, 
it  is  not  any  more  of  a  keratome  than  any  other  knife  that  is  used 
to  incise  the  cornea,  usage  has  made  it  more  entitled  to  the  name 
than  the  others.  Its  origin  was,  in  England,  as  "the  bent  lance." 
and  it  came  to  be  known  in  Europe  as  the  "English  lance-knife." 
It  has  undergone  many  modifications  and   been  put  lo  many  uses. 


CYSTOTOMES  63 

The  present  model  is  essentially  that  given  by  Friedericli  Jager,  and 
its  employment  is  almost  exclusively  confined  to  corneal  incisions 
for  iridectomy  and,  in  short,  all  operations  requiring  a  linear, 
corneal  opening,  of  relatively  limited  extent.  Czermak  recommends 
it  for  making  the  intermarginal  incision  in  restoration  of  the  border 
of  the  lid  in  trichiasis.  The  blade  is  almost  an  equilateral  triangle, 
the  measurement  from  heal  to  point  in  the  median  line,  consti- 
tuting the  altitude,  being  greater  by  one  mm.  than  that  across  the  base. 
The  dimensions  of  the  average  size,  of  which  it  is  well  to  possess 
two,  would  be  9  mm.  for  the  base  and  10  mm.  for  the  altitude. 
Those  of  the  other  two  7x8,  and  loxii  mm.,  respectively.  Jager's 
blade  was  set  at  an  angle  of  about  45°  to  that  of  the  handle.  This 
has  been  found  too  great  a  bend  for  any  but  the  most  deeply  sunken 
eyes.  The  most  convenient  angle  for  all  around  utility  is  about 
35°.  And  I  quite  agree  with  Knapp  in  recommending,  as  has  been 
stated,  that  all  the  keratomes  be  set  at  the  same  angle.  These  four, 
at  any  rate.  On  rare  occasions  a  narrower  and  comparatively 
long  blade,  and  an  ordinary  one,  of  good  size,  mounted  on  a  bayonet 
shank  (Bader's)  would  come  handy — the  first,  for  instance,  in 
certain  optic  iridectomies,  and  the  second  for  extraperipheral 
iridectomy  in  a  subject  with  great  overhang  of  brow.  Landolt's 
well-known  keratome  with  the  broad  curved  shank,  and  the  blade 
with  rounded  corners,  is  a  practical  instrument,  but  as  it  requires 
special  manipulation  because  of  the  peculiar  construction  of  the 
shank,  one  should  have  either  all  or  none  of  this  style. 

Cystotome. — One  is  a  necessity^ — two  would  be  almost  a  luxury. 
Those  in  the  market  are  mostly  modifications  of  \'on  Graefe's. 
It  would  be  better  if  they  were  the  original  model,  for  it  is  a  splendidly 
conceived  instrument.  The  outline  of  the  blade  is  very  suggest i\e 
of  the  side  view  of  a  goose's  head  (Fig.  S3)  It  will  be  obser\-ed 
that  the  back  of  the  head  of  the  goose  is  well  rounded,  and  that 
the  throat,  from  beak  to  neck,  is  a  light  concavity  Now,  what 
passes  in  this  country  as  the  Graefe  cystotome  is  commonly  an 
ugly,  angular  affair,  something  like  that  shown  in  Fig.  34,  being 
a  mere  spike,  or  peg.  The  back  of  the  head  is  a  right  angle  that 
catches  in  the  incision  and  in  the  iris;  and  the  throat  is  another 
angle  in  which  rust  and  bacteria  can  accumulate.  The  idea  seems 
to  prevail  that  only  a  scratching  point  is  required  in  a  cystotome— 
that  a  cutting  edge  is  a  superfluity;  and,  doubtless,  many  a  bungling 
capsulotomy  is  the  result.     A  mere  point  does  not  ntt,  it  simply 


64 


INSTRUMENTS    AND    THEIR    MANAGEMENT 


tears.  The  point  punctures  the  anterior  capsule,  and,  unless  there 
is  an  edge,  and  a  sharp  one  at  that,  to  make  an  incision,  the  alleged 
capsulotomy  is  nothing  but  an  indiscriminate  laceration.  Knapp's 
cystotome  is  an  example  of  an  incisive  one,  but  it  too  is  objectionable 
by  reason  of  its  angularity.  Someone  has  given  to  the  Graefe 
cystotome  a  small  cutting  extension  backward  which  adds  to  its 
efficiency.  The  author  has  used  for  the  past  ten  years  a  cystotome 
on  the  Graefe  principle,  only  the  head  of  the  goose  is  larger,  and  the 
trenchant  part  is  prolonged  a  little  way  into  the  neck   (Fig.  35). 


Fig.  ^3. 


Fig.  34. 


Fig.  35- 


Fig.  -,6. 


Continuing  the  simile,  the  tip  of  the  beak  is  on  a  lower  level  than 
the  top  of  the  head.  In  other  words,  the  back  of  the  blade  is  a 
parabola.  This  disposition  of  the  point  makes  it  easier  to  introduce 
and  to  push  beneath  the  iris  than  if  it  were  on  a  level,  as  is  the  Graefe 
cystotome,  or  actually  in  advance  of  the  rest  of  the  blade,  as  in  the 
Knapp  (Fig.  36).  From  the  back  of  the  head  to  the  tip  of  the  beak 
is  2  mm.  The  center  of  the  crescent  that  constitutes  the  blade  is 
I  mm.  wide,  or  even  11/2  mm.  The  shank  measures  22  to  25  mm. 
The  objects  in  having  it  larger  than  the  Graefe  are  to  make  of  it  a  cut- 
ting instrument  of  greater  significance,  thereby  enhancing  the  pre- 
cision with  which  it  can  be  guided  and  inspected,  and,  in  a  measure, 
to  forestall  the  ravages  of  those  who  afterward  put  it  in  order. 
One  grinding  w\\\  often  reduce  a  smaller  cystotome  to  a  bare  remnant, 
and  leave  no  semblance  of  its  former  shape  This  instrument 
is  not  so  large,  even  at  the  beginning  of  its  career,  as  to  make  its 
size  an  objection.  Of  course,  it  is  not  presumed  that  the  entire 
edge  of  the  blade  will  engage  in  the  cai)sule  at  any  one  o])eration, 
but  it  is  there,  and  ready  to  cut,  if  called  upon.  Contrary  to  what 
has  been  said  relative  to  tlie  length  of  bhide  in  the  cvslotome,  I 


KNIFE    AND    STOP    NEEDLES  65 

have  noted,  time  and  again,  both  in  operating  upon  pigs'  eyes  and 
upon  the  human  subject,  that  the  tiny  spike  of  the  pseudo-Graefe 
instrument,  especially  after  a  few  improvements  ( ?)  at  the  hands  of  the 
sharpener,  failed  to  so  much  as  touch  the  capsule  in  places.  With 
the  anterior  chamber  empty,  and  the  lens  bulging  forward,  its 
anterior  convexity  is  rather  increased,  so  that,  with  an  insignificant 
blade,  unless  one  takes  pains  to  see  that  the  point  is  applied,  by 
lifting  the  handle,  the  shank  will  rest  on  the  summit  of  the  lens, 
in  starting  the  capsumlotoy,  and  the  point  be  thus  kept  from  reach- 
ing the  capsule. 

Knife  Needle. — One  of  these  would  be  thousands.  Were  this 
article  to  specify  the  model,  it  would  be  that  of  Knapp.  Not  the 
pigmy  thing  only  3  or  4  mm.  in  length  one  sometimes  sees  going 
under  this  name,  but  a  blade  of  respectable  proportions,  or  about 
8  mm.  long  and  i  1/2  mm.  wide.  Nor  should  it  have  a  shoulder, 
or  offset,  where  knife  and  shank  unite,  as  is  most  often  the  case. 
This  goes  with  a  jerk  through  the  incision  made  by  the  knife. 
Pagenstecher's  discission  knife  is  also  a  first-class  instrument, 
and  is  well  suited  for  discission  by  the  way  of  the  corneal  base,  or 
the  conjunctival  route,  which  is  fast  becoming  the  only  method.  The 
advantages  of  this  mode,  together  with  a  method  of  preparing  old 
worn  Graefe  knives  for  use  in  the  operation,  in  place  of  needles,  or 
knife  needles,  is  given  in  the  chapter  on  Discission. 

Stop  Needles. — The  various  types  of  discission  needles,  like  the 
long,  straight,  spear-pointed,  the  sickle,  etc.,  have  mostly  fallen 
into  disuse.  One  among  them,  however,  is  still  in  favor.  This  is 
the  stop  needle  of  Bowman.  As  it  owes  its  prolonged  life  to  its 
value  in  the  operation  of  dilaceration,  it  is  best  to  procure  a  pair  of 
them.  In  view  of  the  fact  that  in  this  procedure  the  needles  are 
passed  through  transparent  cornea,  they  should  be  gotten  up  in 
manner  so  slight  and  dainty  as  to  insure  a  minimum  of  traumatism. 
The  little  rhomboid  terminations  ought  not  to  exceed  2  mm.  in 
length  by  i  mm.  in  width.  It  is  best  to  have  the  edges  lightly 
convex,  as  this  not  only  helps  in  penetration,  but  also  gives  lee-way 
for  sharpening  without  spoiling.  The  size  of  the  shaft  between 
rhomboid  and  shoulder  should  be  6  to  7  mm.  long  by  3/5  of  a  mm. 
in  thickness,  and  the  larger,  or  upper,  part  of  the  shaft  should  not 
leave  off  suddenly,  leaving  a  square  offset,  but  should  taper — but 
rapidly — into  the  lower  part.  By  this  arrangement  there  is  no 
sharp  angle  to  catch  dirt,  no  corner  to  injure  the  corneal  epithelium, 
5' 


66  INSTRUMENTS    AND    THEIR    MANAGEMENT 

and,  most  important,  the  sloping  shoulder  serves  as  a  stopper  to 
keep  back  the  aqueous. 

Tattooage  Needle. — This  is  an  instrument  seldom  needed  except 
in  a  large  charitable  clientele,  and  there  they  are  supplied.  Besides, 
as  the  cases  are  not  usually  emergency  ones,  there  would  be  time 
enough  to  get  the  instrument  after  getting  the  patient.  However, 
the  instruments  for  the  procedure  are  described  under  Tattooage 
of  the  Cornea. 

Blunt  Dissector. — For  shelling  out  tumors,  extirpating  the 
lacrimal  sac — in  short,  for  use  wherever  blunt  dissection  is  indicated; 
also  for  loosening  the  periosteum  in  total  exenteration  of  the  orbit, 
the  writer  has  had  constructed  a  modification  of  Fenger's  blunt 
dissector.  Its  blade  is  lanciolate,  lightly  curved  on  the  flat,  has  a 
suspicion  of  transverse  rounding  out  on  the  convex  side,  and  a  low, 
longitudinal,  median  rib  on  the  concave  side.  Its  length  is  3.5 
centimeters,  and  it  is  6  mm.  wide  at  its  middle.      (Plate  I,  21.) 

Sharp  Hooks  (Plate  II). — One,  or  possibly  two,  of  different  pat- 
terns, would  be  ample  in  this  line.  This  is  an  instrument  whose 
place,  in  certain  emergencies,  no  other  instrument  can  quite  fill. 
There  are  two  well-known  classes  of  the  sharp  hook,  viz.,  that  which 
is  very  minute,  and  whose  bend  is  short.  This  class,  of  which  there 
have  been  a  number  of  modifications,  goes  back  to  Beer.  Its 
surviving  representative  is  that  which  bears  the  name  of  Tyrrell, 
and  whose  crook  is  precisely  like  that  of  a  button-hook.  The 
other  class  is  descended  from  the  vectis,  of  Gibson,  but  is  more 
closely  identified  with  Von  Graefe.  Here  the  bend  is  either  angular 
or  but  slightly  curved  and  is  much  less  acute.  The  first-mentioned 
kind  was  destined  solely  for  an  iris  hook,  and  as  such  it  has  chiefly 
been  used.  If,  however,  it  is  given  less  of  the  backward  bend, 
that  makes  it  like  a  button-hook,  and  the  crook  is  opened  out 
somewhat,  it  makes  an  excellent  instrument  with  which  to  deliver 
rather  tough  cataracts  that  are  loosened  and  are  well  forward — 
generally  more  or  less  within  the  anterior  chamber — yet,  that  it  is 
not  practicable  to  get  out  by  pressure.  The  other  hook  has  none 
of  the  backward  bend  in  beginning  the  crook,  but  goes  off  from 
the  shank  almost  at  a  right  angle,  and  is  very  slightly  curved.  Its 
appearance  is  more  that  of  an  old-fashioned  dissecting  tenaculum 
in  miniature.  This  is,  by  far,  the  most  suitable  instrument  with 
which  to  go  fishing  for  luxated  cataracts  that  lie  deeper,  that  is, 
behind  the  iris,  and  for  the  softer  ones  that  are  in  the  anterior 


HOOKS  67 

chamber.  It  can  be  dug  deeper  into  the  lens,  and  more  readily 
than  the  other,  and  if  it  becomes  entangled  in  tissue  that  is  not 
wanted,  it  can  be  more  easily  extricated.  For  remarks  on  its  ad- 
vantages over  other  traction  instruments  in  cataract  operations 
see  chapter  on  the  Immediate  Accidents  of  Extraction.  Suffice  it 
to  say  in  this  place  that,  although  it  is  a  simpler  matter  to  scoop  out 
such  lenses,  along  with  other  things,  than  to  catch  them  deftly 
on  the  hook  without  disturbing  the  other  contents  of  the  globe, 
there  can  be  little  question  as  to  which  is  the  better  method.  Could 
I  have  but  one  of  these  hooks,  I  would  choose  the  one  last  described. 
These  hooks  should  be  of  the  best  steel,  and  exceedingly  fine  and 
delicate.  The  length  of  the  more  curved  one  ought  not  to  be  more 
than  one  mm.,  and  that  of  the  straighter  should  be  i  1/2  scant. 

Blunt  Hooks. — There  are  also  two  kinds  of  blunt  hooks,  but  one 
kind  and  one  hook  is  enough  for  anybody.  Their  only  difference 
is  as  to  size.  Both  were  designed  as  iris  hooks,  i.e.,  for  catching 
the  pupillary  border,  not  as  was  Beer's,  for  catching  in  the  stroma. 
The  larger  is  attributed  to  Himly,  and  is  about  as  lumbering  a 
thing  as  can  well  be  imagined.  The  other  is  known,  in  this  country^ 
as  Tyrrell's.  It  is,  truly,  a  tiny  button-hook,  seeing  that  it  has  not 
only  the  form,  but  the  blunt  point,  as  well,  and  is  much  more 
dainty  than  Himly's.  In  the  sometimes  difficult  task  of  seizing 
with  forceps  the  funnel-shaped  iris  of  aphakial  eyes,  for  instance, 
and  for  the  extraction  of  some  adherent  and  much  shrunken  cataracts, 
Tyrrell's  blunt  hook  will  come  nobly  to  the  rescue.  Its  form  and 
its  smooth,  round  point  peculiarly  fit  it  for  its  insertion  and  with- 
drawal through  the  corneal  wound,  The  mode  of  using  it  is 
described  under  Agnew^s  Blunt  Hook  Operation. 

Squint  Hooks. — There  are  three  standard  sizes  of  such  hooks, 
and  at  least  one  of  each  should  be  provided,  for  each  size  has  its 
appropriate  uses.  There  is  a  vast  difference  in  the  crooks  of 
squint  hooks.  Some  makers  seem  to  think  that  all  that  is  de- 
manded is  to  give  to  a  round  rod  of  steel  of  definite  size  a  given  bend. 
But  those  who  understand  the  exigencies  of  the  instrument  know 
that  the  correct  fashioning  of  its  working  extremity  is  no  mean  job, 
either  as  to  the  configuration  of  the  bend  or  as  to  that  of  the  metal 
comprising  the  bend.  The  bend  is  far  from  a  right-angle  one, 
as  has  often  been  stated.  It  may  be  best  described  as  an  arc  of 
a  circle.  True,  the  chord  of  the  arc  makes  a  right  angle  with  the 
long  axis  of  the  stem  or  shank.     And  it  must  be  insisted  upon  that 


DESCRIPTION  OF  PLATE  11. 


23.  Bowman  stop  needle. 

24.  Tattooage  needles,  round  form. 

25.  Tattooage  needles,  flat  form. 

26.  Beard  extraction  hook. 

27.  Tyrell  blunt  hook. 

28.  Stevens  squint  hook. 

29.  Graefe  squint  hook,  medium. 
29'.   Graefe  squint  hook,  large. 

30.  Prince  divulsor. 

31.  Silver  spatula. 

32.  Tortoise-shell  spatula. 
;^;^.  Daviel  spoon. 

34.  Bunge  exenteration  curet. 

35.  Pagenstecher  e.xtraction  spoon. 

36.  Round  curet. 

37.  Olive  curet. 

38.  Saw-edge  curet. 

39.  Beard  exenteration  knife-spatula. 

40.  Weber  wire  loop. 

41.  Snellen  wire  loop. 

42.  Grooved  foreign  body  spud. 

43.  Flat  foreign  body  spud. 


68 


PLATE  IT. 


IRIS    SPATULA  71 

the  chord  be  that  of  a  true  circle— not  of  a  parabolic  curve.  In 
the  Graefe  hook,  which  is  the  largest  of  the  three  sizes  recommended, 
the  radius  of  the  arc  is  5  mm.,  its  height,  or  rise,  is  2  mm.,  and  the 
length  of  its  chord,  which,  as  said  before,  is  at  90°  to  the  stem,  is 
9  mm.  In  the  intermediate  hook— suggested,  I  think,  by  Landolt — 
the  chord  measures  7  mm.,  and  in  the  smallest,  that  of  Stevens,  it 
measures  5  mm.,  the  rise,  and  the  radius  being  proportionately 
less  The  sides  of  the  hook  are  flattish,  i.e.,  in  cross  section  the 
crook  would  represent  an  oval,  whose  short  diameter  is  constant 
in  every  part  of  the  bend,  being  about  1/2  mm.  for  the  largest  and 
the  intermediate,  somewhat  less  for  the  smallest.  The  long 
diameter  of  the  oval  in  the  Graefe  hook,  gradually  increases  from 
2/3  mm.  at  the  center  of  the  curve,  to  i  1/3  mm.  at  the  free  end,  the 
same  being  true,  though  relatively  less,  as  to  the  other  two.  The 
extremities  in  all  are  smoothly  rounded.  This  form  gives  a  crook 
that  is  readily  inserted  beneath  a  tendon,  is  not  so  slight  as  to  allow 
the  latter  to  slip  off  easily  nor  so  pronounced  as  to  be  difficult  to  dis- 
engage The  Graefe  hook  is  adapted  to  the  work  of  picking  up 
the  tendons  in  enucleation,  and  that  of  holding  the  tendon,  well 
spread  out,  for  the  placing  of  sutures,  etc.  The  medium  hook 
answers  for  the  same  purposes,  but  is  better  adapted  to  the  picking 
up  of  the  tendons  in  tenotomies  and  advancements.  The  Stevens 
hook  is,  preeminently,  the  hook  for  the  partial  tenotomy. 

It  is  remarkable  to  what  an  extent  the  Graefe  squint  hook  has 
become  an  all-around  handy  instrument.  As  examples  of  its  uses 
are  the  following: 

In  extirpation  of  the  lacrimal  canal,  if  the  hook  is  passed  beneath 
the  sac  as  soon  as  that  organ  is  oposed,  the  dissection  is  greatly 
facilitated  by  working  the  hook  up  and  down  between  cupola  and 
the  nasal  duct.  In  the  removal  of  the  corneal  portion  of  a  pterygium 
it  serves  admirably  as  a  divulsor.  In  the  withdrawal  of  bits  of 
iron  or  steel  from  the  interior  of  the  eye  through  a  wound  or  incision, 
the  hook  may,  on  occasion,  and  with  advantage,  be  inserted  at  the 
opening,  then  put  in  contact  with  the  tip  of  the  magnet,  instead  of 
introducing  the  tip  itself.  It  is  employed  to  express  the  lens  in  the 
extraction  of  cataract,  especially  in  the  "Indian"  operation.  It 
is  frequently  made  to  act  as  a  retractor  in  holding  a])art  the  lips 
of  incisions. 

Iris  Spatula.— The  tortoise-shell  spatula  is  an  ideal  instrument, 
and   the  hard-rubber  one  but  little  inferior.     Unfortunately,  they 


72  INSTRUMENTS    AND    THEIR   MANAGEMENT 

cannot  be — at  least,  they  are  not — fastened  to  the  metal  handle  in 
a  manner  that  will  allow  of  their  being  boiled.  They  can,  of 
course,  be  made  aseptic  by  other  means,  but  there  is  a  sense 
of  security  in  being  able  to  boil  all  the  instruments,  for  a 
particular  operation,  that  comes  of  no  other  method  of  disin- 
fection, so  that  every  one  should  be  boilable.  The  best  spatulas, 
to  my  knowledge,  that  conform  to  this  principle,  are  those 
of  silver  and  of  gold.  If  of  the  last,  in  order  to  have  the  re- 
quisite strength  and  elasticity  the  fineness  of  the  metal  should  not 
exceed  lo  k.  The  blade,  including  the  shank,  is  3  1/2  centimeters 
long,  and  is  i  1/2  mm.  wide  throughout,  and  not  more  than  1/4 
mm.  in  thickness  at  the  middle.  It  should  be  lightly  curved  on  the 
flat,  and  the  edge  thinned  down  to  the  point  just  short  of  trenchancy. 
The  extremity  should  be  rounded  and,  if  anything,  there  should  be 
less  thinning  of  the  edge  at  that  point  than  along  the  sides,  to  pre- 
vent wounding  the  iris  in  poking.  It  must  be  seen  to  that  the 
metal  spatula  does  not  have  a  wiry  edge  nor  become  nicked. 

Extraction  Spoons. — Here  too  it  is  a  pity  we  cannot  con- 
sistently enjoy  the  luxury  of  tortoise-shell,  but  we  must  content 
ourselves  with  either  solid  or  German  silver.  Two  are  required- 
one  for  use  behind  the  incision,  the  other  to  make  pressure  from 
below;  the  first  flatter  and  broader  than  the  second.  The  name 
spoon  is  really  applicable  to  the  model  of  this  instrument  only 
so  far  as  it  concerns  the  external  form,  i.e.,  there  is  no  bowl  to 
the  spoon — it  is  solid  or  plain.  They  are  not  intended  for  scoops 
nor  for  curets.  Earlier  spoons  had  a  concavity  because  they  were 
used  to  scoop  or  lade  out  something — usually  more  or  less  of  the 
cataract.  Its  presence,  however,  in  the  expression  spoons  of  to- 
day is  about  as  useful  as  the  appendix  or  any  other  rudimentary 
organ;  and  also,  like  the  appendix,  it  is  simply  a  place  for  things 
to  lodge.  The  outline  of  the  spoons  is  like  that  of  a  pear,  but, 
unlike  ordinary  spoons,  the  broad  end  is  the  one  that  is  free.  Their 
long  axes  measure  about  8  mm.  The  smaller  spoon  measures  4 
mm.  at  the  widest  place,  and  the  larger  5.  The  smaller  is  a  trifle 
over  a  millimeter  in  thickness,  the  larger,  a  trifle  under.  The 
back  is  a  regular  convexity,  i.e.,  without  a  longitudinal  rib,  and 
the  front  is  perfectly  flat.  The  edge  is  faintly  rounded  and  smooth. 
The  broader  spoon  is  the  same  as  that  of  Weber,  excepting  that  it 
is  not  hollowed  out,  and  the  other,  very  similar  to  that  of  Graefe, 
though,  in  addition  to  the  concavity,  the  latter  has  a  great  curve 


CURETS  73 

in  the  shank  that  supi)orts  it.  In  the  shank  of  each  of  those  here 
described  there  is  a  gentle  bend  in  its  terminal  third. 

Curets. — Called  also  Sharp  Spoons.  Every  outfit  should  con- 
tain several  of  them.  One  or  two  fair-sized  ones  for  the  curetment 
of  granulating  pus  cavities,  for  example.  If  two,  it  were  well  to 
have  one  of  them  fenestrated,  as  this  kind  is  easier  both  to  clean  and 
to  sharpen.  Obviously,  it  is  not  so  well  fitted  for  the  double  pur- 
pose of  scraping  and  scooping.  Then,  too,  let  one  be  circular  and 
the  other  oblong.  Their  greatest  diameters  should  not  exceed 
seven  mm.,  nor  the  smaller  four  or  five.  The  depth  of  the  bowl 
must  not  exceed  i  1/2  mm.,  and  it  is  important  that  the  edge 
should  have  a  moderate  tlare.  Then,  a  small  curet  with  finely 
serrated  edge  for  such  work  as  the  obliteration  of  the  sac  or  cyst 
wall  in  the  operation  for  chalazion  and  for  getting  rid  of  little 
islands  of  the  uvea  in  exenteration  of  the  sclera  is  invaluable.  It 
may  be  either  round  or  slightly  oval,  measuring  about  3  mm. 
across.  Without  going  too  extensively  into  curets,  one  might 
also  venture  on  the  acquisition  of  one  for  loosening  the  contents 
of  the  globe  in  exenteration.  The  most  suitable  form  for  it  would 
be  oblong  and  thin,  and  with  a  decided  flare  to  the  edge.  For 
this  purpose  the  writer  prefers  his  exenteration  knife-spatula. 

Exenteration  Knife-Spatula. — This  is  an  improved  instrument 
invented  by  the  writer ^  for  the  removal  of  the  contents  of  the  sclera 
in  the  operation  of  exenteration  of  the  globe  (Plate  II).  As  its  name 
indicates,  it  partakes  in  qualities  and  uses  of  both  knife  and  spatula, 
being  a  little  too  dull  for  a  knife,  and  too  sharp  for  a  spatula.  It 
consists  of  two  parts,  a  blade  and  a  handle.  The  blade  is  double- 
edged,  is  about  4.5  mm,  wide  at  its  broadest  part,  where  it  joins  the 
shank,  and  gradually  tapers  to  the  extremity,  where  it  is  neatly 
rounded.  Its  length  is  about  2.5  centimeters.  It  is  curved  on  the 
flat  for  two-thirds  of  the  distance  from  tip  to  base,  to  correspond  to 
the  meridional  concavity  of  the  sclera,  and  transversely  convex  on  the 
outer  surface  to  fit  the  equatorial  concavity.  Its  inner  surface  is 
flat.  The  edges,  while  not  so  keen  as  is  the  edge  requisite  in  a 
Graefe  knife,  are,  nevertheless,  tolerably  trenchant.  The  rounded 
end  is  blunt— not  bulbous— so  that  puncture  of  the  sclera  may 
be  easily  avoided  The  handle  is  of  aluminum,  to  admit  of  boiling, 
and  blade  and  handle  are  united  by  a  nicely  modeled  shank. 

Wire    Loop. — This    is    sometimes    referred    to    as    Fenestrated 

1  Ophthalmic  Record,  July,  1905. 


74  INSTRUMENTS    AND    THEIR    MANAGEMENT 

Spoon,  which  is  a  very  poor  name,  yet  one  sees  now  and  then  a 
wire  loop  so  clumsy  that  it  might  well  be  thus  designated.  It  is 
needless  to  state  that  the  object  of  this  instrument  is  the  delivery 
of  a  cataract  that  is  luxated  or  has  dropped  into  the  vitreous. 
Seeing  that  it  is  employed  at  a  time  when  there  is  a  large  corneal 
incision  through  which  the  vitreous  is  either  escaping  or  on  the 
verge  of  doing  so,  it  is  of  the  highest  importance  that  a  wire  loop 
introduced  to  bring  out  the  lens  be  so  constructed  as  to  cause  the 
minimum  of  displacement.  It  must,  therefore,  be  made  of  wire 
that  is  as  fine  as  is  consistent  with  the  force  exerted,  and  the  spread 
of  the  loop  must  not  be  needlessly  wide.  If  the  wire  is  stiff  and 
strong — as  it  should  be — its  diameter  need  not  be  more  than  1/3 
mm.  The  greatest  width  of  the  older  Graefe  loop,  was  at  least  6 
mm.,  and  its  total  length  was  i  centimeter.  Weber  modified  the 
loop  by  simply  stretching  it  out,  as  it  were,  making  it  4  mm.  wide 
and  I  1/2  centimeters  long,  but  leaving  the  same  coarse  wire. 
Snellen,  while  adopting  Weber's  loop,  reduced  the  size  of  the  wire. 
Next  to  the  open  sharp  hook,  this  is  the  best  instrument  for  ex- 
tracting lenses  that  cannot  be  expressed,  and,  in  inexperienced  hands, 
it  is  the  very  best.  Snellen's  modification  of  Weber's  would  be  my 
choice. 

Lid  Retractors  (Plate  VIII). — For  three  score  years  the  retractor 
of  Desmarres  has  stood  alone.  Its  inventor  called  it  an  elevateur, 
because  it  was  originally  destined  for  the  upper  lid  alone.  The  only 
change  that  has  been  made  is  the  accentuation  of  the  bend,  i.e.,  in 
the  present  model  the  hook  of  the  lid-holder  is  not  so  widely  open. 
The  trough  of  the  older  retractor  measures  i  1/2  centimeters  across 
the  top;  in  the  newer  model  it  is  only  i  centimeter.  It  is  better 
to  have  two  of  these,  one  for  each  lid  of  adults;  a  larger  for  the 
upper  lid,  the  length  of  the  trough  of  the  lid-holder  measuring 
16  to  17  mm.,  and  a  smaller  for  the  lower  lid,  with  trough  only 
12  to  13  mm.  The  smaller  will  also  answer  for  the  upper  lid  in 
cases  of  small  children.  Those  with  heavily  gold-plated  lid-holders 
and  shanks  are  preferable,  and  their  cost  is  not  excessive.  Fenes- 
trated retractors  have  no  special  advantages  over  the  solid.  Fisher's 
retractor  (see  i)age  551)  is  a  very  handy  instrument  in  that  the  s]n-ing- 
like  handle  lies  fiat  upon  the  head. 

A  very  objectionable  feature  often  noted  in  connection  with  the 
handled  instruments,  such  as  lance  keratomes,  cystomes,  spoons, 
curets,  scjuint  hooks,  and  wire  loops,  is  the  extreme  length  of  the 


SCISSORS  75 

shank.  A  length  of  35  mm.  in  this  part  is  not  uncommon,  and  even 
40  mm.  has  been  observed.  To  hold  these  properly  by  the  handle 
places  the  fingers  too  far  from  the  working  part,  too  far  from  the 
eye  operated  upon,  and  from  the  patient's  face.  Twenty-tw^o  to 
25  mm.  is  about  the  desirable  length. 

So  much  for  the  instruments  of  uniform  handles;  now  for  those 
with  uniform  rings  and  branches,  or  the 

Scissors  (Plate  III). — In  commenting  upon  incongruous  types  of 
scissors  that  one  often  sees  in  the  oculist's  kit,  Landolt  says,  "  When- 
ever we  are  confronted,  among  ophthalmic  instruments,  with  the 
reminiscences  of  the  grosser  surgery  from  which  ours  sprang,  it  is 
most  often  in  case  of  the  scissors."  What  was  true  at  the  time  this 
was  written  is  true  to-day.  Not  only  are  many  of  the  scissors  destined 
for  eye  surgery  conspicuously  coarse  and  big,  but  many  of  them — 
yes,  the  majority — are  lacking  in  the  quality  of  their  steel,  and 
faulty  as  to  the  articulation  of  the  blades.  As  with  the  scalpels, 
it  is  mainly  the  terminal  portion  of  the  blades  that  is  concerned 
while  they  are  in  use.  But,  if  the  coaptation  of  the  blades  is  not 
perfect,  it  is  just  this  part  that  suffers  most.  A  defect  that  occurs 
with  exasperating  frequency  is  the  failure  of  the  edges  to  overlap, 
or  pass  each  other,  at  the  end  of  the  blades,  or  ''forking."  This 
comes  of  the  greater  wear  in  this  location  and  of  the  sharpener 
failing  to  adjust  matters  as  he  should.  The  instrument  will  have 
a  longer  life,  without  undue  shortening  of  its  blades  if  these  over- 
lap very  decidedly  when  new.  Landolt  thinks  that  the  automatic 
fastening  is,  in  a  measure,  responsible  for  the  inferior  cutting 
qualities  of  some  scissors.  Arguing  that,  because  of  one's  ina- 
bility to  tighten  the  fastening  when  the  scissors  get  loose,  as  can 
be  done  with  those  that  are  joined  by  a  screw,  the  only  recourse  is 
to  cramp  the  blades  by  pushing  forward  the  thumb  ring  and  pulling 
back  that  of  the  finger.  This  may  be  true,  but  I  have  been  unable 
to  detect  any  difference  in  the  working  of  the  two  kinds.  The 
advantages  are  largely  on  the  side  of  the  automatic  when  it  comes 
to  a  question  of  keeping  them  free  from  rust  and  filth — that  much 
is  certain. 

With  regard  to  the  rings — these  are  supposed  to  accomodate,  one 
the  thumb,  and  the  other,  the  third  finger  up  to  the  first  joint. 
They  will  then  be  large  enough  for  any  but  digits  of  extra  volume. 
The  problem  is  solved  by  letting  the  regulation  pattern  conform 
to  this   principle   and  compelling    the   acromcgalian  to    have   his 


y6  INSTRUMENTS    AND    THEIR   MANAGEMENT 

scissors  made  to  order.  With  respect  to  the  branches,  there  is  no 
good  reason  why  they,  too,  should  not  be  standardized  as  to  length, 
seeing  that  the  variations  in  the  dimensions  of  the  blades  are  not 
so  great  as  to  be  in  the  way.  With  the  thumb  and  ring  finger 
inserted  as  stated,  and  the  middle  finger  resting  upon  the  outside 
of  the  adjacent  ring,  as  is  the  correct  position  for  holding  the  scissors, 
the  length  of  the  branches  should  be  such  as  to  permit  the  tip  of 
the  index  to  fall  naturally  upon  the  pivot  of  the  blades.  (See 
Fig.  37).  This  means,  for  the  average  hand,  a  measurement  of 
about  5  centimeters  from  the  pivot  to  the  junction  of  branch  and 
ring.  Any  marked  increase  of  this  length  tends  to  cause  wabbling, 
and  any  material  decrease  restrains  freedom  of  action  through  cramp- 
ing the  fingers.  The  scissors  used  by  the  oculist  are  all  so  small 
that  whatever  latitude  is  necessary  in  making  the  relatively  slight 
differences  in  strength  need  not  affect  the  aperture  of  the  rings  nor 
the  length  of  the  branches.     It  is  merely  a  question  of  the  weight  of 


Fig.  37. — Manner  of  holding  scissors. 

these  parts  and  of  the  proportions  given  to  the  blades.  Those  that 
have  branches  4  mm.  wide  by  3  thick,  and  blades  31/2  centimeters 
long,  8  mm.  wide  and  i  1/2  mm.  thick  at  the  base  are  strong  enough 
for  any  of  the  usual  work.  The  daintiest  iris  scissors  have  branches 
2  1/2x2  mm.,  and  blades  21/2  centimeters  long,  5  mm.  wide,  and 
I  mm.  thick  at  the  base.  It  follows,  therefore,  that  there  are  no 
great  differences  in  size  after  all. 

A  question  that  has  often  occurred  to  mc  is:  TT7/y  do  so  many 
pairs  of  scissors  have  sharp  points?  The  instrument  does  not 
advance  by  puncturing  at  two  contiguous  points,  then  uniting  these 
points   by  tearing  the   intermediate  tissue!     Tlic  cutting   point  is 


STRABISMUS     SCISSORS  77 

that  just  where  the  edges  intersect,  which  constantly  moves  forward 
as  the  blades  are  closed.  The  tissue  that  is  being  divided  is  caught 
in  that  angle.  There  can  be  no  office  for  those  needle-like  extremities 
excepting  to  do  mischief.  They  should  be  abolished.  The  tips 
would  simply  need  to  be  blunted  by  slightly  rounding  them.  It  is 
even  doubtful  if  there  is  now  any  branch  of  surgery  in  which  incisions 
are  made  by  first  piercing  the  tissues  with  one  sharp  blade,  then 
closing  down  the  other  to  effect  the  cut.  Formerly  this  was  not  an 
uncommon  practice.  It  is  at  present  confined  to  the  trades. 
Neither  is  there  any  more  a  place  for  the  elbowed  scissors,  with 
one  blade  probe-pointed,  though  they  are  still  with  us,  emeritus, 
as  it  were.  But  enough  of  generalities.  Let  us  make  a  few 
selections. 

Strabismus  Scissors. — -Those  generally  acknowledged  to  be 
best  adapted  to  squint  operations  are  so  small  as  to  be  only  one 
grade  heavier  than  the  iris  scissors  described  a  little  way  back. 
They  are  lightly  curved  on  the  flat.  To  be  more  exact,  the  radius 
of  the  curve  is  4  centimeters,  and  the  bend  is  regular.  This  is  a 
sharp  enough  curvature  for  any  scissors — in  fact,  it  is  about  what 
is  proper  for  all  of  that  character  used  in  eye  surgery.  Yet  one 
often  sees  them  with  a  curve  having  a  radius  of  only  3  centimeters. 
And,  that  the  scissors  may  work  smoothly  and  be  easier  kept  in 
order,  it  is  essential  that  the  curve  maintain  about  the  same  radius 
throughout.  I  say  about  the  same,  for  it  must  be  remembered 
that  this  cannot  be  mathematically  true  of  curved  scissors,  as  the 
curve  of  the  inner  blade  must  be  a  trifle  greater  than  that  of  the 
outer.  This  is  shown  by  the  fact  that  when  the  blades  are  closed 
there  is  always  a  narrow,  crescentic  space  between  them.  The 
blades  of  the  strabismus  scissors  are  about  27  mm.  long,  and  5 
mm.  wide  at  the  base.  From  here  they  taper  to  the  extremity, 
where  the  width  of  the  two,  with  the  scissors  tightly  closed,  is  one  mm. 
and  the  combined  extremity  is  nicely  rounded.  Broad,  clumpy 
ends  would  better  be  rejected.  In  order  to  be  strong  enough,  the 
base  of  the  blade  should  be  i  1/2  mm.  thick  plus,  and,  at  the  end, 
fully  1/4  mm.  This  form  of  scissors  has  a  more  extended  range 
of  application  than  any  other  eye  instrument,  and  one  should  possess 
at  least  two  pairs,  though  it  were  well  to  have  the  second  pair  just 
a  shade  heavier — not  longer.  Stevens'  strabismus  scissors  are  useful 
but  not  notably  better,  for  the  work  for  which  they  were  designed, 
than  are  those  just  described;  and  it  even  seems  that,  by  reason 


DESCRIPTION  OF  PLATE  III. 

44.  Strabismus  scissors,  small. 

45.  Stevens  strabismus  scissors.  ' 

46.  Blunt  strabismus  scissors,  medium.  i 

47.  Blunt  scissors,  curved,  medium.  j 

48.  Sharp  scissors,  curved  on  the  flat.  \ 

49.  Enucleation  scissors,  medium.  j 

50.  Enucleation  scissors,  large. 


7« 


ENUCLEATION    SCISSORS  8l 

of  the  peculiar  narrowing  down  of  their  extremities,  they  "buckle" 
easily  and  are  difficult  to  maintain. 

Enucleation  Scissors. — Having  the  last-named  heavier  scissors, 
a  special  pair,  for  cutting  the  optic  nerve,  are  not  really  necessary. 
To  sever  it,  together  with  the  surrounding  vessels  and  nerves,  would 
put  no  strain  on  scissors  of  this  strength.  Yet  it  is  perfectly  fitting 
to  get  the  extra  pair.  They  should  be  but  a  trifle  heavier  than  the 
stronger  strabismus  scissors.  Their  blades  might  be  3  centimeters 
in  length,  and  their  extremities  a  trifle  broader.  I  have  a  pair  that 
I  purchased  in  Vienna,  while  a  student  there,  the  branches  of  which 
are  9  centimeters  long  and  the  blades  4  centimeters.  The  base  of 
the  blades  is  one  centimeter  in  width.  They  were  regularly  sold 
for  enucleation  scissors.  They  look  now  as  if  they  belonged  to  a 
veterinary  kit. 

Terson,^  of  Paris,  is  the  originator  of  a  pair  of  enucleation  scissors 
that  appeal  strongly  to  one's  sense  of  practicality  and  fitness  (Fig. 
38).  The  blades  are  perfectly  smooth  and  slightly  curved  on  the  flat. 
They  are  of  precisely  the  same  lateral  dimensions,  so  that  when 
closed  their  borders  are  exactly  even.  Their  extremities  are  broadly 
rounded.  Their  most  striking  peculiarities  lie  in  the  fact  that  the 
inner  or  concave  blade  is  extremely  thick,  while  the  outer,  or  convex 


Fig.  38. — Terson's  enucleation  scissors. 

one,  is  proportionately  thin,  and  that  neither  blade  is  beveled  or  cut 
away  at  the  side  corresponding  to  the  edge.  The  thick  blade  holds 
or  pushes  the  globe  forward  at  the  time  the  optic  nerve  is  severed. 
Straight  Scissors. — Two  pairs  of  straight  scissors  are  needed. 
One  extra  strong  pair,  with  blades  31/2  centimeters  long  and  8 
mm.  across  the  base,  for  canthotomy,  cutting  mucous  grafts  from 
the  lip,  enlarging  cutaneous  incisions,  etc.  One  blade  should  be 
heavier  at  the  end  than  the  other,  and  neither  must  be  sharp-pointed. 
The  second  straight  pair  are  built  on  delicate  lines — blades  27  mm. 
long  and  scant  5  mm.  across  the  base,  and  with  the  combined 
rounded  ends  i  mm.  wide.  These  are  best  for  making  straight 
incisions  in  the  conjunctiva  and  in  a  number  of  ways. 

1  Annales  d'Oculist,  Dec,  1905. 
6 


DESCRIPTION  OF  PLATE  IV. 

51.  Small  iris  scissors. 

52.  Luer's  iris  scissors. 

53.  Straight  blunt  scissors. 

54.  Enucleation  scissors  with  hemostatic  clamp. 

55.  Canthotomy  scissors. 

56.  Straight  sharp  iris  scissors. 

57.  Sharp-pointed  angular  scissors. 


PLATE  IV. 


IRIS    SCISSORS  85 

Iris  Scissors. — It  is  customary  among  oculists  to  have  a  pair 
of  extremely  delicate,  curved  scissors  exclusively  for  cutting  the 
iris.  .The  smaller  pair  of  strabismus  scissors  would  do  in  an 
emergency,  though  their  points  are  a  little  too  thick  for  cutting  the 
membrane  close  to  the  cornea.  The  blades  of  the  regulation  iris 
scissors  are  about  21/2  centimeters  long,  4  mm.  across  the  base, 
and  taper  down  to  a  fine,  not  keen,  point  where  the  thickness  of  the 
two  superposed  ends  does  not  exceed  1/3  of  a  mm.  Such  scissors 
are  also  useful  in  the  excision  of  minute  tumors  of  the  conjunctiva 
and  about  the  lid  margins.     They  have  largely  given  way  to  the 

De  Wecker's  Forceps  Scissors  (Plate  VII). — Many  of  the  merits 
of  this  valuable  instrument  are  discussed  in  the  chapter  on  Iridec- 
tomy. It  is  marvelously  contrived,  yet  simplicity  itself.  The  scissors 
arrangement  is  peculiar  in  that  the  blades  are  not  united  by  a 
pivot.  The  fastenings  are  high  up,  one  nearly  midway  of  the 
branches  and  the  other  at  the  top.  The  lower  one  is  so  constructed 
that,  in  closing  the  wings  with  the  fingers,  it  forces  the  branches 
apart.  This  constitutes  the  spring  that  keeps  the  blades  open — 
or  opens  them  after  closure.  The  blades  are  about  7  mm.  in 
length  and  about  i  1/2  mm.  wide  at  the  base.  The  ends  of  the 
blades  are  made  both  blunt  and  sharp,  or  one  blunted  and  the  other 
sharp.  For  my  part,  I  prefer  to  have  them  both  blunt.  The 
scissors  are  set  at  an  angle  of  125°  to  the  branches,  or  a  reverse 
angle  of  55°.  The  entire  length  of  the  branches,  including  the 
button  at  the  top,  is  a  little  more  than  ten  centimeters,  and  their 
greatest  width  8  mm.  These  are  the  dimensions  given  the  instru- 
ment by  De  Wecker  and  by  his  instrument  maker,  Matthieu. 
Common  faults  of  it,  as  it  appears  in  the  shops,  are  heaviness,  too 
strong  a  spring,  and  want  of  proper  coaptation  in  the  blades.  The 
great  advantage  the  forceps  scissors  possess  over  ordinary  iris  scis- 
sors is,  that  by  the  upright  position  in  which  the  instrument  is  held 
while  making  the  excision  of  the  iris,  the  hand  is  brought  close  up  to 
the  site  of  operation,  which  adds  immensely  to  precision.  Besides 
their  legitimate  office  of  cutting  the  iris,  they  are  also  valuable  for  ex- 
tending an  insufficient  corneal  section  in  the  operations  for  cataract. 

Other  Forceps  Scissors. — Any  than  those  of  De  Wecker  are 
seldom  employed;  yet  there  are  times,  as,  for  example,  when  one 
has  to  deal  with  a  dense  membranous  cataract,  a  closed  pupil  with 
aphakia,  that  defies  all  other  means  of  establishing  an  opening, 
when  a  tiny  species  of  scissors,  suitable  for  work  in  the  anterior 


86  INSTRUMENTS    AND    THEIR    MANAGEMENT 

chamber,  becomes  an  absolute  necessity  Fortunately,  these  needs 
are  found  in  the  Charriere  capsule  scissors  or  the  Dowell  iris  scis- 
sors. The  tirst  is  patterned  after  the  ingenius  Desmarres'  capsule 
forceps;  the  second  enjoys  a  most  fitting  model  all  its  own.  Its 
curved  and  forceps-like  branches  and  its  diminutive  pivoted  blades 
make  it  superior  to  Charriere's  as  regards  manipulation.  A  fair- 
sized,  not  too  peripheral,  incision  is  required.     This  brings  us  to  the 

Forceps. — This  group  is  composed  of  many  classes,  and  of  all 
llic  instruments  comprising  our  selection,  the  greatest  number  going 
under  one  common  name  will  be  representatives  of  the  said  classes. 
As  it  is  with  the  scissors,  the  great  trend  of  instrument  makers  is  to 
manufacture  eye-forceps  that  are  too  bulky  and  clumsy,  to  make 
their  springs  too  stiff,  and  to  neglect  properly  tempering  the  steel, 
especially  in  those  with  the  more  delicate  extremities. 

Fixation  Forceps  (Plate  V).— There  are  various  kinds  of  forceps 
used  in  ophthalmic  surgery  more  or  less  for  the  purpose  of  steady- 
ing, or  fixing,  the  parts.  By  way  of  distinction,  therefore,  the  name 
is  almost  wholly  restricted  to  that  which  is  employed  to  immobilize 
the  globe  in  operations  that  involve  it  or  its  external  muscles. 
Among  other  kinds  are  the  rat-tooth,  mouse-tooth,  advancement, 
and  lid  forceps,  etc.,  so,  as  each  of  these  is  well  named,  we  may, 
with  propriety,  restrict  the  term  fixation  forceps  as  stated.  This 
instrument  is  made  either  with  or  without  a  catch  for  locking  the 
jaws.  The  lockable  kind  is  fast  falling  into  disuse,  especially  for 
operations  under  local  anesthesia,  in  which  the  globe  is  opened, 
because  of  their  startling  effect  upon  the  patient  in  unsnapping 
the  catch.  In  narcosis  this  objection  does  not  hold,  but  it  is  some- 
times impossible  to  make  the  thing  let  go  instantly,  as,  for  example, 
when  the  virtreous  is  escaping.  The  catch  is  useful  at  times, 
however,  therefore  it  is  well  to  have  one  pair  with,  and  one  without 
it.  In  all  respects  save  those  referring  to  the  locking  device,  the 
two  instruments  are  alike.  The  best  and  most  elegant  forceps 
of  all  classes,  to  my  notion,  are  those  made  in  Paris,  and  the  dimen- 
sions here  given  relate  to  these.  The  total  length  of  the  fixation 
forceps  is  ii  centimeters  and  3  mm.,  and  the  greatest  breadth  8 
mm.  The  articulating  portion  of  the  jaws  is  4  mm.  in  extent, 
is  provided  with  sharp,  angular  teeth  that  dovetail  together,  and  is 
slightly  concave  to  fit  snugly  against  the  sclera.  Those  in  which 
the  teeth  cross  each  other,  so  as  to  project  slightly  from  the  jaws 
wlicre  the  forceps  is  closed,  are  surer  to  hold.     When  the  teeth  are 


FIXATION    FORCEPS 


87 


insignificant  or  worn  down,  the  holding  power  is  not  to  be  depended 
upon.  As  to  the  locking  variety,  it  behooves  one  to  see  that  the 
catch  works  easily  and  smoothly.  In  case  the  hold  seems  insecure, 
it  can  be  made  firmer  by  picking  up  the  conjunctiva  and  tissue 
beneath  in  a  rather  large  fold  and  giving  it  a  twist. 

Barr  s  Fixation  Forceps.— W.  A.  Barr,  Chief  of  Clinic  in  the 
author's  service  at  the  Illinois  Eye  Infirmary,  has  so  modified  the 


Fig.  39. — liarr's  fixation  forceps. 

ordinary  model  as  to  greatly  improve  it  (Fig.  39).  The  change 
consists  in  imparting  peculiar  curves  to  the  terminal  portions  of  the 
prongs,  and  a  given  angle  to  the  jaws.  These  curves  and  angles 
enable  the  operator  to  apply  the  forceps  to  the  globe  in  such  a  manner 
that  the  hand  which  holds  the  instrument  is  neither  cramped  nor  in 
the  way. 

Beard's^  Fixation  Forceps,  with  the  collaboration  of  Mr.  V. 
Miiller,  an  instrument  maker  of  Chicago,  the  writer,  a  few  years 


Fig.  40. 

ago,  set  about  attempting  to  improve  upon  the  models  of  this  in- 
strument in  general  use.  The  chief  aim  was  to  produce  a  fixation 
forceps  that  would  not  necessitate  the  awkward  bend  at  the  wrist, 
and  the  placing  so  much  in  evidence  of  the  hand  that  steadies  the 
eye  in  such  operations  as  extractions  and  iridectomies.  The 
first  product  of  the  effort  was  an  effective,  though  rather  too  com- 
plicated affair,  whose  jaws  emerged  from  one  end  of  a  tube  by  pressure 
of  the  forefinger  upon  a  knob  at  the  other  end.  This  was  abandoned 
in  favor  of  the  model  shown  in  Plate  VH  and  Fig.  97.  This  is  an 
adaptation  of  Mathieu's  forceps-scissors  to  the  needs  in  question. 
The  scissors  blades  are  left  off,  and  in  their  place  are  the  members 
of  the  forceps.  Instead,  however,  of  moving  in  the  same  sense  as  the 
scissors,  the  lower  portions  of  the  instrument  are  given  a  quarter 
turn,  so  that  they  are  set  in  a  position  at  right  angles  to  that  of  the 

*See  Ophthalmic  Record,  Feb.  1907,  for  more  desirable  text  on  this  forceps. 


DESCRIPTION  OF  PLATE  V. 


58.  Fixation  forceps  without  lock.  j 

59.  Fixation  forceps  with  lock. 

60.  Rat-tooth  forceps.  \ 

61.  Mouse- tooth  forceps.  ,! 

62.  Strabismus  forceps.  ^ 

63.  Dressing  forceps.  J. 

64.  Median  tooth  iris  forceps. 

65.  Forster  capsule  forceps.  j 

66.  Wecker  capsule  forceps.  .j 

67.  Knapp  capsule  forceps. 

68.  Toilet  forceps.  ^ 

69.  Correct  cilia  forceps.  ■  . 

70.  Large  cilia  forceps.  ^ 


&& 


PLATE  \- 


Mmmm 


V 


iil''"'!'''Sli 


MOUSE-TOOTIT    FOECEPS 


91 


scissors.  Thus  it  is  not  necessary,  in  lixing  the  globe  to  turn  the 
tips  of  the  lingers  holding  the  forceps  to  such  extent  that  they  ])()int 
toward  the  operator  (Fig.  41),  and  the  forceps  hand  is  got  out  of 
the  way  and  out  of  the  light  (Fig.  42). 

Rat-tooth  and  Mouse-tooth  Forceps. — These  two  kinds  are, 
as  their  names  would  inij)ly,  distinguished  only  by  their  size — except- 


FiG.  41.— Position  of  hand  hoMin.t,'  --traiglu  forceps. 


ing  that,  rarely,  the  larger  has  a  couple  of  extra  teeth.  The  general 
proportions  of  the  rat-  00th  forceps  are  the  same  as  those  of  the 
fixation  class.  The  jaws,  howe\-er  are  not  extended  laterally,  but 
are  flush  with  the  extremities  of  the  branches.  The  teeth  are  very 
strong  and  about  i  mm.  in  length  There  are  usually  three  teeth, 
so  arranged  that  the  one,  in  the  center  of  one  jaw,  fits  nicely  between 
the  two  in  the  other  jaw,  and,  when  closed,  the  extremity  of  the 
forceps  is  smooth,  i.e.,  the  teeth  do  not  project.     The  mouse-tooth 


92 


INSTRUMENTS    AND    THEIR    MANAGEMENT 


forceps  is  but  a  smaller  type  of  the  same  instrument,  though  it  never 
has  more  than  three  teeth.  It  measures  lo  1/2  centimeters  in 
length  and  6  mm.  where  broadest.  The  larger  kind  can  be  very 
well  dispensed  with,  and  its  place  be  taken  by  the  catchless  fixation 
forceps.  But  the  smaller  is  an  absolute  necessity.  Indeed,  rather 
than  invest  in  one  of  each  kind,  it  would  be  well  to  get  two  of  the 


Fig.  42. — Position  of  liand  holding  Beard's  forceps. 

mouse-tooth.  When  the  mouse-tooth  forceps  is  defective,  it  is 
usually  as  regards  the  teeth.  They  lack  size  and  strength  or  they 
do  not  interlock  perfectly. 

Dressing  Forceps. — These  are  exact  counterparts  of  the  mouse- 
tooth  forceps  excepting  that,  instead  of  teeth,  the  inner  aspect  of 
the  jaws  presents  a  series  of  transverse  serrations.  A  mistake  often 
seen  in  the  make-up  of  this  forceps  is  that  only  the  terminal  tips 
of  the  jaws  come  in  ap])osilion  williout  undue  pressure  upon  the 


IRIS    FORCEPS  93 

branches.  There  should  be  contact  for  two  or  three  mm.  without 
squeezing.  This  is  the  most  suitable  forceps  to  aid  in  removing 
sutures.  It  also  makes  a  good,  all-around,  toilet-forceps,  and  is 
valuable  for  handling  the  thread  in  advancement  operations.  One 
is  a  plenty. 

Iris  Forceps. — There  exist  a  great  number  of  varieties  of  this 
instrument,  yet  there  are  but  two  in  ordinary  use,  and  they  are  all 
that  one  needs  to  procure.  These  are  distinguished  only  by  the 
disposition  of  their  teeth,  and  are  known  as  median-tooihcd  and 
Z)ac^-toothed.  In  general  construction,  the  median-toothed  is 
like  the  mouse-tooth  forceps,  the  only  difference  being  in  the  size 
and  shape  of  the  extremities.  The  terminal  thirds  of  the  branches 
are  cut  down  to  about  1/3  the  dimensions  of  the  mouse-tooth,  and 
they  are  made  to  end  in  a  gentle  curve  that  lies  in  the  same  plane 
as  the  fiat  of  the  branches.  This  curve  extends  for  one  centimeter 
from  the  end  of  the  forceps,  and  it  has  a  radius  of  about  6  mm. 
There  is  considerable  diversity  in  the  inclination  of  the  chord  of  the 
arc  that  constitutes  the  curve,  with  reference  to  the  axis  of  the  forceps. 
As  it  is  with  the  blades  of  the  lance-keratomes,  so  should  it  be  with 
this  inclination,  i.e.,  it  should  be  the  same  in  the  several  forceps. 
A  convenient  angle  for  the  chord  is  45°.  That  is,  the  grand  angle 
is  135°.  The  roughening  on  the  branches  that  serves  to  give  it  a 
safe  hold  to  the  fingers  is  situated  lower  down  than  it  is  in  the  mouse- 
tooth  forceps.  This  is  the  forceps  for  all  uncomplicated  iridectomies. 
For  iridectomies  in  cases  where  there  is  posterior  synechia,  or 
for  those  in  aphakial  eyes,  etc.,  the  back-tooth  iris  forceps  is  the  more 
serviceable.  Here  the  teeth,  instead  of  being  situated  between  the 
opposing  ends  of  the  branches,  arise  from  the  back,  or  convex, 
edges  of  the  branch  terminals.  In  the  one  instance  the  bite  of  the 
teeth  is  at  right  angles  to  the  axis  of  the  forceps,  and  in  the  other, 
parallel  with  it.  In  one,  the  teeth  are  flush  with  the  ends  of  the 
blades,  in  the  other  flush  with  the  back  edges  of  the  blades,  and  on 
one  side  with  the  end  also.  It  is  a  serious  fault  in  this  variety  to 
have  the  teeth  at  a  little  distance  from  the  end  of  the  branches  on 
both  sides,  for  in  attempting  to  seize  the  iris  that  membrane 
might  be  pushed  down,  out  of  reach  of  the  teeth,  by  the  free  end 
of  the  forceps.  The  back-tooth  forceps  often  have  five  teeth — two 
fitting  the  interspaces  of  three.  Forster's  are  thus.  Sometimes 
there  are  more  than  five.  Again,  the  teeth  are  directed  somewhat 
backward  and  project  in  interlocking;  or  they  are  made  bayonet 


94  INSTRUMENTS    AND    THEIR    MANAGEMENT 

fashion,  i.e.,  arc  made  to  occupy  a  ])lane  still  farther  back  than 
the  posterior  edge  of  the  jaws.  Such  arrangements  have  very 
doubtful  advantages  and  some  serious  drawbacks.  The  projecting 
teeth  make  them  difficult  to  insert  without  catching,  and,  with  the 
long,  sharp,  projecting  teeth,  there  is  danger  of  wounding  the  lens 
if  the  latter  is  present.  Indeed,  these  more  savage  instruments 
are  only  fitted  for  capsule  forceps.      (Page  556.) 

Capsule  Forceps. — For  the  occasional  thickened  capsules,  and 
for  those  of  adherent  lenses,  a  forceps  is  needed  for  tearing  the 
membrane  off  and  extracting  it— a rrachement.  Those  that  bear 
the  name  of  De  Wecker  serve  the  purpose  well.  They  are  some- 
thing between  the  ordinary  back-tooth  forceps  and  those  exaggerated 
ones  just  mentioned  in  that  their  teeth  occupy  a  very  slight  offset 
at  he  back  of  the  jaws.  This  forceps  can  be  made  to  do  very  well 
in  place  of  the  back-tooth  forceps.  Like  all  the  small  toothed 
forceps  they  must  be  closely  watched  to  see  that  the  teeth  are  neither 
broken  off  nor  out  of  line  with  their  notches. 

An  important  point  in  the  selection  of  iris  and  capsule  forceps, 
if  not,  indeed,  as  regards  that  of  all  the  ophthalmic  forceps,  is  to 
make  sure  that  the  springs  by  which  they  open  are  not  too  stiff". 
"In  order  to  manipulate  an  instrument  with  the  greatest  delicacy 
and  certainty,  said  manipulation  must,  like  the  simple  hold  between 
the  fingers,  call  for  the  least  possible  force.  In  other  words,  the 
strength  which  we  must  exert  to  hold  our  iris  forceps  shut  destroys 
just  that  much  of  the  nicety  and  precision  in  handling  the  instru- 
ment and  of  the  daintiness  of  touch.  While  insisting  upon  it 
that  the  springs  be  soft,  let  it  not  be  understood  that  the  branches, 
or  members,  themselves  should  be  flexible.  On  the  contrary, 
they  must  be  firm  and  rigid.  This  principle  is  illustrated  by 
examining  certain  forceps  and  noting  that  the  extremities  of  their 
jaws  open,  instead  of  closing,  when  their  (too  weak)  branches  are 
pressed  upon. 

Rotary  Iris  and  Capsule  Forceps.— To  this  class  belong  those 
of  Liebreich  and  of  ^latliicu,  and  their  advantages  are  explained 
in  the  chapter  on  "Operations  Upon  the  Iris." 

Toilet  Forceps.— For  making  the  toilet  of  the  eye  after  iridecto- 
mies and  extractions  the  dressing  forceps  arc  not  well  adapted,  being 
too  straight  and  too  big.  Hence,  the  small,  curved  toilet  forceps 
of  De  Wecker,  are  recommended.  This  is  nothing  more  nor  less 
than  or(h'nary   iris  forceps,   dc])rivcd   of  their  teeth   and  supplied, 


FORCEPS    CONTINUED  95 

instead,  with  the  fine  crosswise  roughening  similar  to  the  dressing 
forceps.  Like  it,  too,  there  should  be  contact  of  the  jaws  for  a 
short  distance  from  the  ends  of  the  branches— say  for  about  i  mm. 

Cilia  Forceps. — A  scientil'ically  wrought  cilia  forceps  is  not 
always  to  be  had.  Most  of  them  arc  ])a(l.  Landoll  says,  "I  can- 
not fancy  what  evil  genius  ]nirsucs  this  lilllc  instrument.  It  seems 
to  be  fated  to  bear  a  form  that  is  neither  graceful  nor  suited  to  its 
purpose.  Time  and  again,  and  unceasingly,  cilia  forceps  are 
fabricated  that  have  jaws  as  big  as  shovels,  heavy  enough  to  crack 
nuts,  and,  in  shape,  suggestive  of  the  hoofs  of  a  horse  placed  base 
to  base"  (Plate  V,  No.  70).  It  is  precisely  this  horse-foot  construc- 
tion that  constitutes  the  objection  most  frec^uently  found  in  cilia 
forceps.  That  is  to  say,  the  area  of  the  opposing  surfaces  of  the 
jaws  is  too  great  or  it  reaches  too  far  from  the  tip.  Hence,  in  at- 
tempting to  pull  out  a  fine  hair,  through  squeezing  together  the 
branches  the  proximal  edge  of  the  broad  articulating  facet  acts  as 
a  fulcrum,  to  pry  open  the  distal  parts  of  the  jaws,  and  the  hair 
is  let  go.  An  effective  cilia  forceps  would  be  about  85  mm.  long, 
8  mm.  wide  in  the  broadest  places,  and  the  branches  should  be  of 
good  thickness  (Plate  \',  No.  69).  The  roughening  for  the  fingers 
should  be  carried  to  within  1.5  cm.  of  the  extremity  of  the  jaws. 
The  latter  should  not  be  more  than  2  to  2.5  mm.  wide,  by  1/2  mm. 
deep,  and  should  have  their  articulating  surfaces  elevated  i  mm. 
above  the  inner  planes  of  the  branches,  and  be  perfect  with  respect 
to  coaptation.  To  interpose  a  peg  or  pin  between  the  branches  in 
such  a  way  that  it  will  not  permit  of  their  being  bent  inward  by  too 
much  pressure  of  the  fingers  is  a  good  idea.  Moderate  pressure  in 
epilation  gives  better  results  than  does  excessive. 

Advancement  Forceps.— To  those  who  feel  the  need  of  forceps 
for  clamping  and  holding  the  tendon  in  squint  operations,  I  would 
recommend  Prince's  advancement  forceps.  Their  jaws  are  set 
at  an  angle,  in  the  plane  of  the  flat  of  the  branches,  consist  of  one 
spiked  member  and  one  correspondingly  perforated  one — or,  in 
technical  phraseology,  of  one  male  and  one  female  member.  For 
the  rest,  the  instrument  is  identical  with  the  locking  lixation  forceps. 
This  is  a  simpler  and  more  effective  tendon-clam])  than  is  that  of 
De  Wecker. 

Trachoma  Forceps. — This  subject  is  treated  of  in  the  chapter 
on  the  "Surgical  Treatment  of  Trachoma." 

Lid  Forceps  and  Clamps  (Plate  \'l). — In  this  class  are  included 


DESCRIPTION  OF  PLATE  VI. 


Prince  advancement  forceps. 


71 

72.  Prince  expression  forceps. 

73.  Knapp  expression  forceps. 

74.  Noyes  expression  forceps. 

75.  Kuhnt  expression  forceps. 

76.  Warlamont  adjustable  lid  clamp. 

77.  Beard  lid  forceps. 

78.  Desmarres  lid  clamp. 

79.  Wilder  chalazion  forceps. 

80.  Hunt  chalazion  forceps. 


96 


PLAl'E  VI. 


HEMOSTATIC   FORCEPS  99 

not  only  all  the  forceps  used  for  holding  and  fixing  the  lid,  but  also 
the  lid  clamps.  In  fact,  the  two  instruments  cannot  be  separated 
into  distinct  classes,  as  one  merges  into  the  other.  True,  there  are 
lid  forceps  and  lid  clamps,  pure  and  simple,  but  more  often  it  is  a 
combination  of  forceps  and  clamp.  The  modern  lid  forceps  spring 
from  "  Jager's  T  forceps.  The  original  is  still  in  use,  as  it  deserves  to 
be.  Of  course,  it  needs  a  locking  attachment.  This  should  be  either 
the  sliding  catch  or  the  old-fashioned  screw,  for  in  these  the  force 
of  the  grip  can  be  regulated.  The  spring  catch  does  not  admit 
of  any  adjustment,  either  as  regards  grip  or  thickness  of  lid.  Du- 
jardin's  T  forceps,  on  the  same  principle  as  Jager's,  are  too  savage, 
because  of  their  teeth.  Lid  clamps  are  usually  some  modification 
of  that  of  Desmarres,  i.e.,  the  essential  features  are  a  plate  to  go 
beneath  the  lid,  a  ring,  whose  circumference  coincides  with  the 
outer  border  of  the  plate,  and  a  slide,  or  a  screw,  to  lock  the  branches. 
Knapp  and  Snellen  enlarged  the  plate  and  left  off  that  part  of  the 
ring  corresponding  to  the  free  border  of  the  lid.  In  order  to  still 
further  enlarge  the  field  for  operating  within  the  ring,  Warlomont 
has  devised  an  expansible  plate  that  spreads  out  like  a  fan.  This 
is  placed,  unexpanded,  into  the  upper  fornix,  when,  by  turning  a 
screw  on  the  end  of  the  handle,  the  moveable  parts  of  the  plate  can 
be  made  to  flare  so  as  to  put  the  cul-de-sac  upon  the  stretch.  The 
ring  coincides  with  the  expanded  plate.  This  is  evidently  an  im- 
provement over  the  older  models  when  it  is  a  question  of  the  more 
extended  entropion  operations,  for  example,  as  greater  scope  is 
afforded  for  free  incisions.  But  for  smaller  operations,  like  chalazion, 
etc.,  the  others  are  just  as  good,  and  they  are  far  simpler  and  easier 
as  to  their  keeping.  For  chalazion,  Wilder's  clamp  is  handy. 
(See  "Chalazion.")  For  fixing  or  steadying  the  lid  and  for  clamp- 
ing it  to  prevent  hemorrhage  in  restoration  of  the  free  border,  as 
also  in  median  tarsorrhaphy,  and  to  fix  it  in  electrolysis  of  the  cilia, 
the  lid  forceps  invented  by  the  writer^  (Plate  VI,  No.  79),  is  an 
efficient  instrument.  The  branches,  being  attached  at  the  ex- 
tremities of  the  jaws,  are  out  of  the  way  for  work  on  either  side  of 
the  clamp. 

Hemostatic  Forceps. — One  must  have  two  or  three  of  the 
lightest  pattern — Tate's  or  Halstead's  model.  Those  with  long 
branches — measuring  9.5  centimeters  from  the  pivot  to  the  extremity 
of  the  rings — are  less  in  the  way  than  ihe  short,  or  dwarf,  kinds,  as 

'  Ophthalmic  Record,  Jan  ,  1905. 


DESCRIPTION  OF  PLATE  Vll. 

8i.  Liebreich  rotary  iris  forceps. 

82.  De  Wecker's  forceps  scissors. 

83.  Sand's  needle  forceps,  with  duck-bill. 

84.  Knapp's  needle  forceps. 

85.  Noyes  iris  scissors. 

86.  Dowel  scissors. 

87.  Todd  tendon  tucker. 
97.  Beard  fixation  forceps. 

08.  Halsted  mosquito  hemostatic  forceps. 


PLATE  VII. 


NEEDLE    FORCEPS  IO3 

the  latter  necessitate  placing  the  hand  that  liolds  them  close  to  the 
seat  of  operation.  The  jaws,  from  ])i\()t  to  end,  sliould  not  exceed 
2.5  centimeters.  The  working  extremity  of  the  jaws  should  be  2 
mm.  wide,  and  slightly  rounded.  The  branches  are  best  if  light 
and  elastic.  Those  with  a  series  of  notches  for  the  catch  are  con- 
venient, simple,  and  effective. 

Needle  Forceps. — Those  constructed  upon  the  principles  em- 
bodied in  the  still  highly  approved  instrument  devised  by  Sands, 
of  New  York,  are  the  favored  of  all  eye  surgeons.  The  circular 
jaws  of  the  Sands  forceps  have  mostly  been  discarded  for  the  more 
desirable  duck-bill  jaws,  and   instead  of  deep  grooves  for  receiving 


Fig.  43. — Stephenson's  needle  forceps. 

the  needle,  thus  limiting  the  number  of  positions  in  which  it  can 
be  placed,  the  surfaces  of  the  jaws  are  either  simply  roughened 
or  else  they  are  lined  with  metal  softer  than  steel,  such  as  copper. 
It  has  been  urged  that,  without  the  grooves,  curved  needles  are  more 
apt  to  be  broken.  This  is  contrary  to  my  observation.  Some  clever 
genius — some  say  Knapp,  some  De  Wecker,  some  Weiss — thought 
to  turn  the  free  end  of  the  lever  toward  the  handle,  whereas,  in 
the  Sands  model,  it  is  toward  the  jaws.  This  arrangement  puts  the 
hand  that  holds  the  instrument  further  away,  and  permits  not  only 
greater  freedom  of  movement,  but  more  room  for  handling  the 
other  implements  concerned  in  the  operations.  The  snap  catch  is 
to  be  preferred  to  the  slide,  as  its  manipulation  is  easier  and  causes 
less  joggling.  It  adds  to  steadiness  and  leverage  if  a  transverse 
plate  is  attached  on  the  side  opposite  the  catch,  whereon  to  rest 
the  forefinger.  This  plate  is  lightly  guttered  to  ht  the  index.  The 
closer  the  lever,  or  the  catch,  to  the  jaws,  the  less  unsteadiness  in 
letting  go  of  the  needle,  hence  those  needle  forceps  that,  like 
hemostatic  forceps,  have  the  catch  at  the  ends  of  the  handles  are 
objectionable.  It  would  really  seem  more  scientific  to  employ 
a  simple  grip  forceps,  without  a  calch,  wlienever  practicable,  as 
the  shock  and  twisting  consequent  u])on  tlie  unlocking  are  doubtless 
pernicious.  Needle  forceps  without  any  form  of  lock  or  catch  are, 
however,  of  doubtful  value  in  any  kind  of  eye  surgery.     The  great 


DESCRIPTION  OF  PLATE  VIII. 

88.  Jaeger  lid  spatula. 

89.  Mules  repositor. 

90.  Mellinger-Beard  blepharostat  solid  lid  holders. 

91.  Mellinger-Beard  blepharostat  fenestrated  lid  holders. 

92.  Landolt  nasally  operated  eye  speculum. 

93.  Irrigation  retractor. 

94.  Small  Desmarres  retractor. 

95.  Desmarres  retractor. 

96.  Terson  enucleation  shield. 
100.  Conical  dilator. 


104 


PLATE  VIII. 


lU.KI'IIAkOSTATS  107 

objection  being  that  I  hey  cannol  be  so  deflly  turned  about  in  the 
hand  to  assume  the  \arious  re(|uisile  i)()sitions  without  dropjjing 
the  needle  from  their  grasp.  In  order  to  obtain  more  freedom 
and  ease  of  handhng,  one  often  shifts  the  hand  back  to  the  extremity 
of  the  handle.  This  is  a  movement  of  which  the  catchless  forceps 
will  not  admit.  Moreover,  there  are  certain  advantages  in  using 
a  needle-holder  that  can  be  conveniently  handed  to  the  operator 
ready  "loaded"  by  an  attendant.  A  good  model  of  the  simpler 
forceps  is  shown  in  F'ig.  43. 

Blepharostats  (Plate  VIII),  or  eye  speculums,  as  they  are  popu- 
larly called,  can  be  quickly  disposed  of.  There  is  no  end  to  their 
variety,  but,  since  the  appearance  of  the  Mellinger  speculum,  most 
of  the  others  have  been  relegated  to  the  scrap-heap.  Practically  all 
of  its  predecessors  had  branches,  of  greater  or  less  length,  pivoted 
at  one  extremity,  carrying  lid-holders  of  divers  configuration  at  the 
other,  and  bearing,  somewhere  between  the  branches,  a  more  or  less 
complicated  locking,  or  setting,  device.  As  a  result  of  the  increasing 
divergence  of  the  branches  in  the  opening  of  these  blepharostats, 
the  tendency  is  to  pry  the  lids  farthest  apart  at  the  free  end  of  the 
lid  holders.  Gaupillat  dared  even  put  pivoted  lid-holders  on,  to 
obviate  this  defect.  Then,  the  catches,  ratchets,  screws,  levers, 
and  things  with  which  the  locks  were  operated— contrivances  more 
cantankerous,  especially  at  critical  moments,  it  were  dilTicult  to 
imagine.  Both  these  faults  were  done  away  with  at  once  in  the 
Mellinger  instrument.  Its  branches  remain  parallel  in  all  stages 
of  separation,  and  its  locking  is  accomplished  in  a  truly  automatic 
manner.  The  tighter  the  lids  grip  the  holders,  the  more  rigid  the 
branches,  yet  no  degree  of  gripping  can  interfere  wdth  instant  closure 
of  the  blepharostat.  Moreover,  the  lids  can  be  forced  apart  by 
simply  pressing  upon  the  ends  of  the  sHdes.  The  first  of  these 
blepharostats  were  unnecessarily  heavy  and  big,  and  the  length  of 
the  handle  or  lever  portions  of  the  branches  was  out  of  pro])()rtion 
to  that  of  the  arm  portion.  Some  years  ago  the  writer  suggested 
the  lengthening  of  the  handles  and  the  shortening  of  the  arms,  thus 
affording  more  leverage  for  the  operator's  fingers,  and  less  for  the 
patient's  lids;  and  also  the  lightening  and  reducing  of  the  whole 
mechanism  so  as  to  make  it  more  delicate  and  compact.  Two  years 
ago  he  set  about  making  an  improvement  in  the  lid-holders  and  in 
the  spring,  especially  designed  for  cataract  operations.  One 
objectionable   feature   of   the   majority  of  lid-holders   had    l)een    a 


IC8  INSTRUMENTS    AND    THEIR    MANAGEMENT 

bar  that  rested  beneath  the  \u\.  ]\Iany  and  many  an  eye  has  been 
sacrificed  to  this,  i)articuhirly  in  operations  for  the  extraction  of 
cataract,  by  its  catching  in  the  wound.  Another  was  that  the 
cilia  and  the  ducts  opening  in  the  Hd  border  were  suffered  to  polkite 
the  site  of  operation.  The  Landolt  model  has  not  the  bar,  but  it 
has  the  other  objection.  Only  the  old,  solid  lid-holder  of  Weiss, 
(or  Laurence)  was  free  from  both.  Yet  in  all  other  respects,  the 
Weiss  blepharostat  is  a  ^•ery  clumsy  affair,  the  lid-holders  being 
merely  two  straight  gutters,  adapted  neither  to  the  curve  of  the 
free  border  nor  to  the  convexity  of  the  globe.  Gaullipat  and  Lang 
overcame  one  of  these  defects  by  making  the  bottom  of  the  trough 
convex,  in  order  to  fit  the  concavity  of  the  lid-margins.  In  addi- 
tion to  this  curve  the  blepharostat  shown  in  Plate  \' IK,  No.  90,  has 
another  at  right  angles  to  the  first,  by  which  the  inner  wall  of  the 
gutter  is  made  to  conform  to  the  convex  surface  of  the  globe,  and  the 
outer  wall  to  that  of  the  outer  surface  of  the  lid.  Moreover,  the  inner 
wall  of  the  trough  is  made  decidedly  lower  than  the  outer,  so  that 
its  rim  will  not  press  up  in  the  fornix,  as  such  pressure  tends  to 
produce  spasm  of  the  orbicularis  and  to  restrict  the  rotation  of  the 
globe  when  the  patient  attempts  to  look  downward,  the  very  direc- 
tion in  which  he  should  look  during  most  operations.  The  impor- 
tance of  this  feature  will  be  appreciated  when  it  is  remembered  that 
the  conjunctival  sacs  of  many  of  the  cataract  subjects  are  shrunken 
and  the  cul-de-sacs  shallow.  The  comfortable  way  in  which 
the  lids  are  held  apart  with  this  form  of  blepharostat  reduces  the 
inclination  to  squeeze,  and  the  eye  can  be  rolled  upward  repeatedly 
without  risk  of  eversion  of  the  corneal  flap.  The  shape  of  the  lid- 
holders  renders  them  a  trifle  less  easy  to  put  in  place  than  some  others, 
but  this  is  not  to  be  considered  in  comparison  with  the  readiness 
and  safety  with  which  the  instrument  may  be  removed.  I  first 
thought  that  it  would  be  needful  that  one  should  have  a  pair  of  such 
blepharostats — a  right  and  a  left — with  a  smaller,  straighter  trougli 
for  the  lower  lid.  This  was  found  to  be  an  error.  Indeed,  the 
manner  in  wdiich  the  present  form  depresses  that  lid  gives  unusual 
opportunity  for  manipulation  of  the  fixation  forceps.  The  whole 
appliance  is  made  of  solid  nickel,  hence  easily  kept  bright.  Tlie 
arms,  being  flat,  can  be  easily  bent,  in  the  fingers  in  order  to  adapt 
the  blepharostat  to  the  varying  prominences  of  eye  and  temple. 
This  obviates  any  need  of  the  jointed  arms  which  were  also  a  part  of 
the  very  ingenious  Gaupillat  blepharostat  of  some  twenty  years  ago. 


PROBES    AND    NEEDLES  .  lOQ 

With  regard  to  the  spring,  it  was  discovered  that  its  loose  ends 
could  become  jammed  in  the  slot  through  which  glide  the  slides, 
and  that  so  tightly  as  lo  make  any  movement  of  the  arms  impossible. 
Besides,  the  springs  were  made  of  steel,  which  soon  got  rusty  and 
out  of  true.  At  my  suggestion,  the  Messrs.  Miiller,  who  made 
the  modified  instrument,  put  on  spiral  springs  of  non-corrosive 
material,  and  with  the  wire  at  their  extremities  soldered  into  a 
continuous  circle.  The  spring  has  barely  sufficient  strength  to 
keep  the  grooves  of  the  lid-holders  applied  to  the  free  borders  and 
not  strong  enough  to  stretch  the  eye  open  too  forciljly. 

Jager's  Lid  Spatula,  or  Horn  Plate.  (Plate  \III,  Fig.  88.) 
— This  well-known  and  serviceable  implement  must  be  in  every 
oculist's  outfit. 

Lacrimal  Probes  and  Sounds  are  discussed  in  the  chai)ter 
relating  to  the  surgery  of  the  lacrimal  apparatus.  I  beheve,  how- 
ever, that  Weber's  conical  sound  is  not  mentioned  there.     This  is 


Fig.  44, 

a  valuable  instrument,  but  rather  than  have  the  "double-header" 
kind,  I  would  choose  two  distinct  instruments,  having  the  top 
portion  merely  for  a  handle  (see  Fig.  44) . 

Sewing  Needles. — Aside  from  a  very  few  special  kinds,  the 
ophthalmic  surgeon  habitually  employs  the  various  grades  of 
regularly  curved  needles.  The  radius  of  the  main  extent  of  the 
curve  of  the  finest  needles  is  about  i  centimeter.  From  this  they 
gradually  increase  up  to  about  1.7  centimeters,  which  is  about  the 
radius  of  the  coarsest.  The  length  of  the  needle  corresponds  to 
about  1/3  the  circumference  of  a  circle.  More  highly  curved,  or 
those  including  more  than  1/3  of  the  circumference  of  the  circles 
thev  represent,  are  not,  as  a  rule,  desirable.  A  si)ecial  needle, 
for  use  in  advancement  operations,  is  described  under  "JMuscular 
Advancement."  All  needles  are  supposed  to  have  sharp  edges  as 
well  as  sharp  points,  and  their  eyes  should  be  smooth  and  rounding 
where  the  thread  strain  falls,  and  a  large  as  practicable.  The 
so-called  self-thrcadcrs  are  all  right  for  most  operations,  but  for 
those  in  which  it  would  be  disastrous  to  break  the  thread,  they  are 
not  to  be  trusted,  for  they  cut  the  strands,  thus  causing  both  ir- 
regularity and  weakness. 


no  INSTRUMENTS    AND    THEIR    MANAGEMENT 

A  certain  number  of  ordinary  probes  and  cotton  carriers,  pref- 
erably silver,  and  our  selection  is  complete. 

Manipulation  of  Instruments.— In  this  connection,  Landolt, 
with  characteristic  terseness,  remarks,  "Just  as,  by  the  mere  act 
of  grasping  a  foil  and  putting  himself  on  guard,  the  classic  fencer 
is  distinguished  from  the  pretended  swordsman,  so  is  a  surgeon 
of  correct  training,  the  moment  he  touches  an  instrument,  dis- 
tinguished from  the  autodidactic  operator.  The  last  may  succeed, 
for  example,  in  extracting  a  cataract  without  losing  the  eye— his 
work,  as  a  whole,  may  be  attended  with  fairly  good  results— but 
no  one  will  deny  that,  in  point  of  perfection  of  results  and  number 
of  successes,  the  advantage  will  always  lie  on  the  side  of  right 
training." 

How  obtain  this  training  ?  Assuredly  not  standing  around  oper- 
ating tables  and  "  looking  on !' '  One  would  as  \vell  try  to  become  an 
expert  billiard  player  in  the  same  way.  A  start  can  be  made  under 
the  instruction  of  one  fitted  to  teach.  Not  necessarily  a  linished 
nor  a  famous  operator.  Surgery,  in  this  regard,  is  like  music — 
not  all  who  excel  in  imparting  a  knowledge  of  the  art  are  adepts  in 
its  execution,  and  vice  versa.  Having  been  grounded  in  the  elemen- 
tal principles,  constant  practice  is  indispensable.  In  the  beginning 
only  upon  the  fresh  eyes  of  animals  fixed  in  a  mask  and  upon  those 
of  the  cadaver.  Later,  upon  those  of  the  living  human  being,  but 
always,  during  periods  when  sufficient  opportunity  is  not  afforded 
for  this,  keeping  up,  at  least,  the  work  on  the  animals'  eyes.  Then, 
to  train  the  fingers  to  that  suppleness  and  precision  of  movement 
that  are  of  inestimable  value  to  the  eye  surgeon,  all  manner  of  odd 
moments  are  utilized.  It  suffices  for  this  simply  to  go  through 
with,  over  and  over,  the  dift'erent  motions  appropriate  to  the  more 
important  surgical  measures,  either  with  the  instruments  pertaining 
thereto,  with  purely  make-believe  articles,  such  as  pens  or  pencils, 
or  with  imaginative  ones,  holding  nothing.  While  those  move- 
ments pertaining  to  the  wrist  and  forearm  are  not  to  be  neglected, 
those  of  the  fingers  come  first.  In  addition  to  nimbleness  and 
guidableness,  the  fingers  must  possess  delicacy  and  sensitiveness  of 
touch.  These  are  attained  both  by  systematic  exercises,  similar 
to  those  given  the  blind  in  teaching  them  to  read,  and  in  acquiring 
knowledge  of  many  external  things,  and  by  the  scrupulous  care  of 
the  hands,  particularly  of  the  skin  thereon.  The  avoidance  of 
needless  wetting  of  llie  hands  with  solutions  that  destroy  the  epider- 


MODES    OF    GRASPING 


mis,  by  wearing  suitable  gloves  when  engaged  in  any  work  or  exercise 
that  would  otherwise  lead  to  roughness  of  the  skin,  etc.  The 
great  advantages  to  be  gained  from  ambidexterity  are  too  well  recog- 
nized to  be  dwelt  upon  here,  but  unless  the  surgeon  is  truly  ambi- 
dexter it  were  far  more  wise  and  prudent  to  sacrifice  the  mere 
personal  advantages,  or  conveniences,  to  precision  and  safety  as 
regards  the  operation  and  its  result. 

Modes  of  Grasping  Instruments.— A  great  deal  depends  upon 
degree  of  pressure  exerted  by  the  lingers  upon  the  object  held.  Too 
tight  a  grip  tends  to  tremor,  lack  of  motility,  and  general  awkward- 
ness; too  light  a  one,  to  want  of  precision  and  to  actual  escape 
of  the  instrument  from  the  fingers.  The  happy  mean,  then,  would 
be  to  grasp  light  enough  to  insure  the  greatest  freedom  of  move- 
ment consistent  with  a  secure  hold.  After  this  comes  the  exact 
position  of  the  lingers  relative  to  the  part  grasped.  This  varies 
both  as  to  the  character  of  the  instrument  and  as  to  the  use  it  is 
being  put  to  at  the  moment.  First,  as  to  the  instruments  with 
handles.  Much  has  been  said  about  the  "penholder  fashion"  of 
holding  eye  instruments.  This  is  a  poor  illustration.  A  penholder 
is  held  steadily  by  the  tip  of  the  thumb,  the  pulp  of  the  index,  and 
the  inner  side  of  the  first  phalanx  of  the  mediiis.  The  motion  im- 
parted to  the  pen  is  mainly  that  of  the  forearm.  No  turning,  or 
rotation  of  the  implement  is  practised  or  required.  Obviously, 
it  is  quite  another  matter  when  it  comes  to  guiding  the  objects  under 
consideration.  The  great  factors  in  the  manipulation  of  the 
handled  instruments  are  the  thumb  and  the  index.  Between  these 
the  handle  is  grasped,  and  by  them  it  is  rotated— solely,  as  concerns 
its  long  axis,  and  partly  as  regards  the  other  axes.  To  these  ends, 
the  two  are  placed  more 
directly  opposite,  even  in 
the  so-called  pen-holder 
grasp,  than  they  are  in 
writing — many  times  di- 
rectly opposite,  with 
their  pulps  applied^ — and 
the  medius  plays  a  de- 
cidedly secondary  part  Fu;.  45 -Pen-holder 
in  both  holding  and  guiding  (Fig.  45).  Its  functions  are  to 
lightly  support  the  grasp  and  to  give  an  occasional  touch  in  guid- 
ance.    Rotations  of  the  handle,  on  its  transverse  axes,  are  accom- 


INSTRUMENTS    AND    THEIR    MANAGEMENT 


plished  in  great  measure  by  turning  the  entire  forearm,  though  it 
is   surprising   to  what   an   extent   trained   fingers  can  effect  these 

movements  also.  The 
wrist-joint  —  i.e.,  whole- 
hand  movement — is  called 
into  requisition  much  less 
often  in  ophthalmic  than 
it  is  in  general  surgery. 
Upper-arm  movements  are 
to    be   limited,  but    in    no 

Fig.  46.-1.1  extraction  right.  ^^.^^  restricted. 

Detailed  specification  as  to  the  exact  manner  of  holding  and 
directing  each  of  the  instruments  with  handles  would,  without 
practical  demonstration,  be  only  tedious  and  confusing.  More 
can  be  ascertained  rela- 
tive to  the  grasp  by  look- 
ing at  the  accompanying 
illustrations,  than  by  writ- 
ten descriptions  (Figs.  45 
to  51).  Besides,  many 
points  in  the  manipula- 
tions, peculiar  to  individ- 
ual operations,  are  given 
in     connection     with     the 


-In  extraction  left. 


Fig.  47. 

technic  of  the  procedure  as  it  occurs   in  the  body  of  this  book. 
For  the  rest,  the  reader  must  look  to  other  sources. 

A  word,  however,  as  to  the  "fiddle-bow"  method  of  holding  the 

scalpel,  as  shown  in  cut 
(Fig.  48).  The  name, 
while  a  little  more  appro- 
priate than  that  of  "pen- 
holder" to  the  grasp  in 
point,  only  describes  it  in 
part.  For  here  the  index 
is  usually  placed  on  the 
upper  side  of  the  handle, 
near  the  end  that  carries 
the  l)lade.  The  ])ul])S  of  the  second  and  tliird  fingers  are  placed 
side  by  side  about  midway  of  the  handle,  on  one  side,  and  the 
thumb  on  llie  olhcr  side,  jusl  ()p])()site.      The  Utile  linger  is  best 


Fig.  48. — Fiddlo-ljow. 


'OSnioX    OF    SURGEON 


"3 


left  free.  This  mode  is  specially  conformable  to  incisions  ihal  arc 
made  from  left  to  right,  as  regards  the  ojierator,  or  from  right  to  left 
when  executed  with  the  left  hand. 

Then,  too,  the  position  of  the  surgeon  with  resjject  to  his  patient, 
as  in  extractions  and  iridectomies,  has  much  to  do  with  the  manner 
of  holding  and  manipulating  certain  instruments.  If  one  stands 
at  the  head,  for  a  cataract  operation,  for  example,  the  Graefc  knife 
is  pilled  toward  the  operator  in  making  the  section;  if  for  an  iridec- 
tomy, the  keratome  is  pushed  away  from  him.  Whereas,  if  one 
stands  at  the  side  of  the  table,  or  facing  the  patient,  the  opposite 
is  true — the  Graefe  knife  is  pushed, 
and  the  keratome  is  pulled.  The 
same  is  true  of  the  other  instru- 
ments, that  is,  the  technic  of  their 
handling  is  reversed.  With  the  sec- 
tion upward,  in  the  usual  direction, 
and  standing  at  the  head,  the  tips  of 
the  iris  forceps  are  pushed  into  the 
anterior  chamber,  the  iris  is  seized 
and  pulled  out.  The  spoon  that  de- 
livers the  cortex  is  pulled.  Standing 
at  the  side  these  movements  are  Fig.  49 
made  in  the  opposite  sense.  Each  of 
these  positions  has  its  advantages,  and  ophthalmic  surgeons  are  fairly 
well  divided  as  to  their  choice  in  the  matter.  It  is  best  to  study 
carefully  one's  aptitude,  and  facility  of  maneuver,  in  each  place 
•f  occupancy,  then  to  adopt,  and  remain  constant  to,  the  one  to 
which  he  finds  himself  better  fitted.  As  concerns  the  control  of 
the  patient's  "line  of  regard"  the  position  at  the  side  would  seem 
the  preferable  one.  If,  for  instance,  the  patient  hears  the  operator 
say  "Look  at  me,"  he  will  instinctively  direct  the  eyes  toward  the 
sound  of  the  voice,  whether  he  can  see  or  not.  Said  direction  will 
be  slightly  downward,  and  is  precisely  that  which  is  the  most  favor- 
able for  the  entire  operation  of  extraction.  Of  course,  to  stand  in- 
variably in  cither  place  one  must  be  ambidextrous. 

The  handling  of  instruments  other  than  those  with  handles  is 
treated  of  further  on,  where  occasion  demands.  The  method  of 
holding  the  scissors  is  given  on  page  76.  A  word  here  as  to  turn- 
ing them  over  while  in  the  hand.  This  is  a  maneuver  that  is  in  fre- 
quent requisition  with  curved  scissors.  The  index  is  removed  from 
8 


-Manner  of  holding  kera- 
tome— pulling. 


114 


INSTRUMENTS    AND    THEIR    MANAGEMENT 


its  position  with  tip  resting  on  tlie  pivot,  and  dropped  back  to 
place  it  opposite  the  medius.  These  two  serve  then  to  hold  the 
scissors,  while  the  third  finger  and  thumb  are  removed  from  the 
rings.  This  is  done  in  the  order  named,  and  the  third  finger,  on 
emerging,  gives  the  ring  that  it  just  left  a  push  to  turn  it  in  the 

direction  of  the  thumb;  this, 
in  turn,  on  coming  out,  pushes 
the  other  ring  toward  the 
third  finger,  and  the  latter  is 
at  once  inserted.  The  thumb 
is  then  put  into  the  remain- 
ing ring,  and  the  tip  of  the 
index  put  back  in  its  place  on 
the  pivot.  To  be  able  to 
manipulate  scissors  equally 
well  with  either  hand  is  an 
art  acquired  by  a  very  few 
surgeons.  It  is  highly  con- 
venient   in  that  it  often  ob- 


FiG.  so. — ^^anner  of  holding  keratome- 
pushing. 


viates  changing  one's  position  bodily. 

The  handling  of  iris  and  capsule  forceps  is  peculiar  in  that  it 
rests  almost  exclusively  with  the  fingers  (Fig  51).  The  pulps  of 
index  and  medius  are  placed  on  one  branch,  one  at  either 
extremity  of  the  roughened  area,  and  the  thumb  in  the  middle 
of  the  other  roughened  area.  The  jaws  are  advanced  into  the  an- 
terior chamber  by  a  sort  of  pulling  backward  on  the  part  of  the 
index  and  a  pushing  for- 
ward on  that  of  the  me- 
dius, the  thumb  being, 
meanwhile,  the  pivot,  so  to 
speak,  on  which  the  instru- 
ment turns.  In  withdraw- 
ing the  jaws,  precisely  the 
reverse  occurs.  This  is 
one  place  where  the  mid- 
dle finger  is  called  upon 
for  some  fine  work. 

The  Care  of  Instruments. 


ManiKT  of  holding  iris  forceps,  pushing. 


First  as  to  the  receptacles  in  which 
they  are  kei)t  or  in  wliich  they  are  carried.  A  great  deal  has  been 
said  in  ridicule  and  dis])aragcment  of  the  ornate  cases,  all  lined 


INSTRUMENT    I5()XF,S  II5 

wilh  silk  and  \cl\cl;  coNcred  with  morocco,  and  j^arnished  willi  ihe 
name  of  the  owner  in  nourishes  of  gold,  the  idea  being  that  tiiey 
were  unfit  for  holding  surgical  instruments  because  of  one's  inability 
to  wash  and  scrub  them;  that  they  should  be  manufactured  only 
of  materials  thai  will  bear  being  boiled  or  immersed  in  powerful 
antiseptic  solutions.  Now,  while  it  is  true  that  those  fancy  things 
are  somewhat  out  of  harmony  with  the  recognized  principles  under- 
lying modern  surgery,  it  is,  after  all,  really  only  a  matter  of  taste 
or  fashion  whether  one  keeps  his  instruments  in  boxes  bedecked 
with  beautiful  stuffs  or  in  those  of  hard  wood  and  metal  unadorned. 
The  box  in  neither  case  is  of  itself  antiseptic,  nor  are  the  instru- 
ments presumed  to  be  ready  for  use  the  moment  they  are  taken 
from  the  box.  If  the  decorated  box  will  not  bear  soaking  in  strong 
antiseptic  liquids,  no  more  will  the  others.  The  silk  and  vehet 
and  the  leather  can  be  w^ashed  clean  w^ith  naphtha  and  disinfected 
with  formalin,  and  that  is  sufficient  for  any. 

Granting,  then,  that  one  is  at  liberty  to  choose  the  material  for 
his  instrument  cabinets  and  his  instrument  boxes,  I,  for  one,  would 
select  hard  wood.  The  rarer  and  finer  and  harder  the  wood,  the 
better.  A  glass  shelf  or  two  might  be  allowed  in  a  cabinet,  but 
there  should  be  no  grand  array,  flauntingly  exposed  to  view  in 
plate-glass  show-cases,  suggestive  of  a  pathologic  museum.  For 
the  most  part,  these  should  be  made  up  of  very  shallow  drawers, 
of  the  same  wood  as  the  rest.  The  location  of  the  drawers  is  such 
that  none  is  inconvenient  because  of  being  too  near,  or  too  far 
from,  the  floor.  Each  drawer  has  its  lock,  and,  in  addition,  a 
device  to  prevent  it  from  being  drawn  clear  out  of  the  cabinet. 
In  these,  however,  only  the  instruments  in  constant  use  should  be 
kept.  For  the  handled  instruments  there  w^ould  be  racks  of  the 
corresponding  wood  or  of  ebony,  and  each  notch  therein  should  be 
fitted  to,  and  set  aside  for  some  particular  instrument,  and  the 
different  objects  should  be  arranged  according  to  their  characters, 
i.e.,  the  retractors,  the  spoons,  the  hooks,  the  knives,  the  needles — • 
each  group  should  have  its  allotted  space.  The  scissors  and 
straighter  forceps  would  have  their  drawers  and  racks,  and  be 
held  in  their  places  by  delicate  springs.  The  jaws  of  the  forceps 
would  be  kept  closed  by  the  action  of  the  spring  that  serves  as  a 
rack.  All  articles,  such  as  blepharostats,  odd-shaped  forceps,  etc., 
and  those  not  easily  damaged  would  be  loose  in  the  drawers,  or 
in  separate  compartments  therein.     For  the  more  j^articular  odd 


Il6  INSTRUMENTS    AND    THEIR    MANAGEMENT 

ones,  their  indi\idual  compartments  in  the  drawers  should  have 
hinged  or  sHding  covers.  There  will  always  be  a  certain  treasured 
assortment  to  be  guarded  apart,  to  be  spared  the  vicissitudes  of 
ordinary  handling — good  new,  or  newly  repaired,  knives  and 
scissors  and  the  like.  And  none  shall  be  left  in  boxes  standing 
about  for  thoughtless  ones  to  overturn  or  meddle  with.  Super- 
posed trays,  with  racks,  etc.,  are  apt  to  be  the  cause  of  more  harm 
than  of  good  to  the  instruments,  by  falling,  tipping,  jamming  and 
crushing.  For  transporting  small  selections  of  instruments  for 
appointed  operations,  at  hospitals  or  other  places,  a  series  of  small 
boxes,  each  containing  from  one  to  four  or  five  articles,  is  better  than 
putting  all  or  any  considerable  number  into  one  container.  If 
a  box  be  let  fall,  or  if  one  is  lost,  the  consequent  damage  or  loss 
will,  in  this  way,  be  minimized.  The  more  delicate  or  more 
valuable  the  instruments,  the  fewer  in  a  box.  Knives  are  placed 
in  the  racks  edge  downw^ard.  An  exception  is  made  as  regards 
lace-knives,  which  are  placed  pointing  to  the  left.  These  boxes 
can  be  put  together  in  a  leather  bag  or,  what  is  better,  stuck  around 
in  the  different  pockets  of  one's  clothing.  The  rounded  nickel 
boxes  with  racks,  and  holding  springs  projecting  from  the  under 
side  of  their  lids  are  splendidly  adapted  to  carrying  in  the  pocket. 
For  the  non-cutting  instruments  all  that  is  needed  is  the  plain 
nickel  box,  with  rounded  corners — i.e.,  without  racks  or  springs. 
A  layer  of  absorbent  cotton  is  put  in  first,  then  the  instruments, 
then  enough  cotton  laid  on  top  of  them  to  prevent  rattling  about. 
If  forceps  are  put  into  such  a  box,  each  should  have  a  section  of 
rubber  tub  ng  slipped  over  its  branches  to  keep  its  jaws  closed. 
Before  boiling,  the  rubber  must  be  removed,  else  a  tarnished 
streak  will  appear  at  the  place  it  occupied.  Also,  in  boiling,  the 
delicate  ends  of  instruments  should  be  wrapped  in,  or  wound 
with,  absorbent  cotton,  to  protect  them  from  injury.  All  knives 
should  be  clamped  in  racks  before  boiling. 

To  Protect  From  Rust. — If  steel  instruments  are  put  away  dry 
they  seldom  rust.  Especially  is  this  true  of  those  that  are  kept  in 
dry  buildings  and  of  those  in  daily  use.  Such  as  are  out  of  present 
use  or  arc  being  kept  for  any  reason  would  better  be  given  a  coat 
of  cocoa  butter,  vaselin,  or  lard.  This  refers  not  only  to  the 
plain  steel  instruments,  but  also  to  those  plated  with  nickel;  for 
steel  in  these  is  often  exposed  in  places.  Apropos  of  nickel  ])lating, 
it  should  cover  all  steel  instruments  except  the  blades  of  knives, 


CARE    OF   POINTS    AND   EDGES  II7 

the  edges  of  scissors,  and  the  jaws  of  forceps.  The  custom  of 
leaving  it  off  iris  forceps  and  a  few  others  is  inexpHcable.  After 
using,  these  instruments  are  washed  first  with  cool  water  to  remove 
blood,  etc.,  then  immersed  in  very  hot  water,  and,  lastly,  wiped  with 
soft  linen,  then  dipped  in  benzin  or  gasoline,  and  allowed  to  dry 
spontaneously.  This  last  process  has  the  effect  of  leaving  upon  the 
metal  an  insensible  coating  of  oil  which  effectually  prevents  rust. 
While  it  is  no  more  than  proper  that  the  water  should  be  sterile  in 
each  instance,  it  is  not  necessary  to  use  any  antiseptic.  These  are 
only  for  use  preparatory  to  the  operation.  It  need  hardly  be  ex- 
plained that  the  reason  the  instruments  are  not  put  directly  into 
the  scalding  water  after  being  used  is  because  blood,  or  other  albu- 
minoid substances  with  which  they  are  soiled  would  be  thus  coagu- 
lated and  made  difficult  to  get  off. 

It  has  been  asserted  in  many  quarters  that  the  process  of  boiling 
both  corrodes  and  dulls  steel  instruments.  This  is  not  borne  out 
by  experience  and  observation.  If  one's  experience  is  that  his 
instruments  have  suffered  in  this  manner  he  has  probably  failed 
to  observe  that  it  was  due  to  something  else  than  the  mere  boiling. 
Most  often  it  is  because  they  have  remained  wet  for  a  time  after 
having  been  taken  out  of  the  sterilizer.  Sometimes  it  is  the  result 
of  impure  water  used  for  the  boiling.  As  an  extra  precaution 
against  rust,  it  is  important  to  put  a  little  sodium  carbonate 
(NagCOg)  1%,  or  sodium  hydrate  (NoOH)  0.25%  into  the  w^ater. 
Of  all  the  kinds  of  moisture  to  which  instruments  are  exposed, 
there  is  none  more  corrosive  than  that  from  sweaty  hands. 
Therefore,  after  handling  only,  it  were  better  if  the  article  were 
washed  in  hot  water  and  dried.  Wiping  without  previous  wetting 
would  not  suffice  to  remove  the  salts  deposited  on  the  metal  from 
the  evaporated  perspiration.  Seeing,  however,  that  this  will  rarely 
be  done,  let  it  be  urged,  at  least,  that  they  be  thoroughly  wdped. 

Our  instruments  are  put  through  hot  water  after  cleansing  with 
the  object  of  insuring  rapid  drying,  and  not  that  one  may  dispense 
with  the  wiping  of  them.  The  drying  is  as  essential  as  the  washing, 
and  the  time  to  do  it  is  while  the  instruments  are  fresh  and  hot  from 
their  bath.  It  is  of  special  importance  that  attention  be  given 
to  all  angles,  joints,  etc.,  to  make  sure  that  no  moisture  remains  in 
them. 

Care  of  Points  and  Edges.— The  worst  enemies  of  these  are 
careless  and  untrained  attendants  about  hospitals  and  offices,  and 


Il8  INSTRUMENTS    AND    THEIR    MANAGEMENT 

conscienceless  and  unskilled  workmen  in  the  repair  shops.  The 
lirst  knock  them  about,  rattle  them  together,  and  jab  them  into 
things,  and  the  second  grind  them  out  of  all  form  and  substance, 
and  deprive  them  of  their  temper  or  rightful  hardness.  Hence, 
the  less  these  persons  are  intrusted  with  our  sharp  instruments,  the 
])ctter  off  we  shall  be.  If  the  bottom  of  a  vessel  containing  liquid 
into  which  instruments  are  to  be  immersed  is  covered  with  two  or 
three  layers  of  gauze  it  will  keep  them  from  sliding  abeut  and  being 
damaged.  Certainly,  as  concerns  the  more  delicate  and  responsible 
articles  it  were  decidedly  to  the  advantage  of  those  most  interested, 
i.e.,  the  patient  and  the  operator,  if  the  surgeon  himself  took  sole 
charge  of  their  care  and  maintenance,  even  to  the  sharpening  of 
them.  He  who  is  not  already  schooled  in  such  matters  can  usually 
acf(uire  the  requisite  training  without  difficulty.  If  he  cannot  be 
an  expert,  he  can  at  least  become  enough  of  a  dab. 

Unless  a  knife  or  a  needle  meets  with  some  accident,  as  a  fall  or 
a  jam,  whereby  the  edge  or  the  point  is  positively  damaged,  no 
grinding  upon  them  is  ever  necessary.  They  are  then  never  dull 
in  a  gross  sense.  All  they  need,  even  after  having  been  repeatedly 
used,  is  honing  and  polishing.  These  are  best  accomplished  by 
means  of  a  fine  strop  and  the  best  of  rouge  pomade.  Pastes  contain- 
ing gritty  substances,  as,  for  instance,  pumice  or  emery — no  matter 
how  linely  these  substances  are  powdered — are  ruinous,  and  ought 
scrupulously  to  be  avoided.  If  a  point  be  broken  or  turned,  or 
if  a  blade  be  nicked,  the  proper  remedy  is  cautious  grinding  on 
a  whet-stone  of  good  quality,  with  the  liberal  use  of  vaselin  or 
cold  water.  The  great  desiderata  are  to  obtain  the  maximum 
of  keenness  or  of  trenchancy  with  the  minimum  loss  of  substance 
and  to  preserve  the  correct  model  of  the  working  ])arl  of  the 
instrument. 

Testing. — The  most  suitable  material  on  which  to  test  the  degree 
of  shar])ness  of  eye  instruments  is  known  as  French  trial  kid.  This 
means  ihc  thinnest  and  most  delicate  tanned  kid — preferably  of  an 
animal  that  has  not  gone  to  tlie  full  term  of  gestation — and  not 
split  goatskin  nor  the  still  more  objectionable  shagreen,  which  is 
made  from  horses'  hides.  The  instrument  is  commonly  tested  with 
the  kid  stretched  over  a  drum.  I  ])refcr  to  dispense  with  the  drum 
and  mani[)ulate  \hv  leather  with  the  lingers  The  ])oinl  of  a  knife 
or  a  needlr,  lo  be  right,  must  pass  llirough  tlic  kid  without  a  jog 
or  au(h'ble    tick,    and     almost    without   sensil)le   resistance.     Kera- 


KNIFE    TESTING  IIQ 

tomes,  bistouries,  cataract  knives,  and  knife-needles  should  have 
their  entire  edges  tried,  from  point  to  heel.  In  severing  the  kid 
they  should  not  emit  a  distinct  sawing  or  ripping  sound.  This 
indicates  a  too-pronounced  serration,  which  is  only  appropriate  to 
the  larger  scalpels  and  to  the  grosser  instruments  generally.  A 
single  puncture  or  incision  is  sufficient,  as  repetitions  only  result 
in  loss  of  sharpness. 

To  try  scissors  they  are  closed  down  tightly,  making  a  cut  in  the 
kid,  then  removed  from  it  with  blades  still  closed.  If  the  points 
hang  or  catch  the  leather  in  the  least  the  condition  of  the  instrument 
is  faulty.  Either  there  is  dullness  at  the  extremities  of  the  blades 
or  else  there  is  a  tendency  to  fork.  Both  are  bad,  for  the  reason  that 
the  very  tips  of  the  blades  constitute  in  the  scissors  the  only  parts 
that  actually  engage  the  tissues.  Wantonly  opening  and  shutting 
scissors,  when  they  are  not  in  real  use,  is  highly  pernicious,  as  it 
spoils  their  edges,  producing  roughness  and  grating.  This  can  be 
made  to  disappear,  when  not  too  far  gone,  by  passing  the  edge  of 
the  thumb-nail  or  other  smooth  object  of  similar  hardness  along  each 
blade,  pressing /ro;;z  the  flat,  or  articulating  side,  toward  the  bevel. 

A  BALANCE  FOR  KNIFE  TESTING. 

Smith,  Priestly,  Birmingham  (Ophth.  Review,  Aug.,  1903),  has 
devised  a  simple  instrument  to  determine  by  actual  measurement  the 
pressure  which  we  have  to  emplo)'  to  cut  or  puncture  the  leather  of  the 
test-drum.  It  resembles  a  see-saw  in  miniature.  One  arm  of  the  beam 
carries  a  small  drum  covered  with  the  thin  white  kid  (shagreen)  sold  for  this 
special  purpose;  the  other  is  marked  with  a  scale  indicating  grammes, 
and  carries  a  sliding  weight  which  gives  to  the  drum  an  upward  pressure 
varying  from  o  to  18  grams. 

To  test  the  point  of  a  knife  the  drum  is  placed  in  a  horizontal  plane,  the 
point  gently  pressed  against  the  leather,  and  the  weight  moved  until  the 
knife  persistently  punctures  the  leather  instead  of  depressing  the  beam. 
All  punctures  should  be  made  in  the  transverse  diameter  of  the  drum  so  as 
to  be  at  the  same  distance  from  the  fulcrum. 

To  test  the  edge,  the  drum  is  placed  on  edge,  vertically,  and  the  knife, 
passed  through  a  slit  in  the  leather,  is  pressed  downward  without  thrusting 
or  sawing.  Using  a  given  piece  of  leather  for  all,  a  number  of  knives  may 
be  compared  and  placed  correctly  in  order  of  merit.  We  can  measure 
the  effect  on  a  given  knife  of  immersion  in  boiUng  water,  of  antiseptic 
fluids,  or  of  use,  and  compare  various  models  of  puncturing  or  cutting 
instruments. 

Good  Graefe  knives,  new  or  newly  sharpened,  puncture  at  a  pressure  of 
I  to  2  grams.  They  cut  at  from  10  to  14  grams,  and  with  a  tight 
leather  some  of  them  at  8  grams.  As  a  rule,  they  cut  more  easily  near 
the  point.  Cataract  needle-knives  cut  at  14  to  18  grams.  Cystotomes, 
new,  punctured  at  4  to  8  grams;  resharpened,  at  10  to  18  grams. 


CHAPTER  III. 
OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE. 

THE    LACRIMAL   APPARATUS. 

Dilating  the  Punctum. — Probes  or  sounds  and  the  canulas  of 
lacrimal  syringes  up  to  one  millimeter  in  diameter  may  be  passed 
through  the  undivided  punctum  by  first  stretching  this  opening 
somewhat.  The  measure  usually  suffices  to  reestablish  the 
punctum  when  superficially  closed. 

The  Most  Suitable  Instrument  is  the  conical  probe  or  stylet  of 
Landolt  (Plate  VIII,  No.  loo),  a  modification  of  Bowman's  "di- 
rector." The  kinds  commonly  on  sale  by  the  dealers  in  surgical 
instruments  have  cones  that  are  too  long,  slender,  and  sharp.  Their 
excessive  length  and  slenderness  are  objectionable  because  they 
necessitate  a  maximum  of  entrance  into  the  canal  with  a  minimum 
of  dilatation  of  the  punctum.  The  point  of  the  excessively  long 
ones  might  bring  up  against  the  lacrimal  fossa  ere  the  stretching  was 
sufficient.  Their  sharpness  of  point  is  objectionable  for  the  reason 
that  it  is  apt  to  wound  the  walls  of  the  canal,  causing  false  tracts, 
etc.  The  cone,  then,  should  not  exceed  two  centimeters  in  length, 
gradually  tapering  from  a  diameter  of  two  millimeters  at  the  shank 
to  that  of  one-third  of  a  millimeter  at  the  point.  The  latter  should 
be  neatly  rounded  or,  better  still  perhaps,  have  an  olive-shaped  bulb 
whose  greatest  diameter  could  be  one-third  to  one-half  a  millimeter. 
Every  eye  surgeon,  doubtless,  has  noticed  with  what  facility  a  tiny 
bulbous  extremity  on  knife  or  probe  will  enter  the  punctum.  The 
dilator  or  stylet  should  have  a  handle  to  itself,  i.e.,  not  at  one  end 
of  a  handle  that  it  shares  with  another  instrument  at  the  other  end. 
These  double  instruments,  of  which  a  number  have  been  made,. 
do  not  conform  to  correct  ideas  of  modern  aseptic  surgery. 

To  Dilate  the  Punctum,  the  patient  may  lie  on  a  tabic,  but  ii 
is  better  that  he  sit  in  a  low  chair,  A  towel  is  put  over  his  hair. 
The  operator  stands  behind  the  chair  for  the  lower  puncta,  and 
offers  his  chest  as  a  support  for  the  patient's  head.  Supposing  it 
is  the  right  lower  punctum,  the  left  thumb  is  placed  midway  of 
the  lower  lid,  ])rcssc'(l  down  li,i:;ht  on  llic  lower  rim  of  llie  orl)il  lt> 

120 


LACRIMAL    PROBES  121 

slightly  evert  the  punctum  and  put  it  on  the  stretch  toward  the 
temple  to  resist  the  inward  pull  of  the  probe.  This  pressure  by 
the  thumb  helps  also  to  steady  the  patient's  head.  The  patient 
is  told  to  look  upward,  the  probe,  anointed  with  sterile  vaselin,  is 
inserted  vertically,  then  immediately  turned  to  the  horizontal  and 
pushed  along  the  canaliculus  till  the  dilatation  is  deemed  sudicient 
and  thus  held  for  a  few  moments.  When  the  progress  of  the  cone 
becomes  a  little  difficult,  slight  rocking  of  it  on  its  long  axis  will  aid 
its  further  entrance.  If  syringing  or  probing  is  to  follow  the  dilata- 
tion, an  assistant  stands  by,  holding  the  lacrimal  probe  or  syringe, 
as  the  case  may  be.  When  it  is  time  to  withdraw  the  dilator,  this 
is  resigned  to  the  assistant,  the  operator  takes  the  probe  or  syringe, 
places  the  tip  of  the  canula  at  the  punctum,  and,  still  holding  the 
lower  lid  down  and  out  and  patient  looking  steadily  up,  the  as- 
sistant withdraws  the  dilator,  and  before  the  opening  has  time  to 
contract,  the  canula  or  probe  is  introduced.  Treatment  of  the 
lacrimal  canal  with  dilator  and  syringe  will  often  result  in  closure  of 
the  punctum  within  a  very  few  hours  because  of  the  rawness  and 
tissuring  induced  about  its  rim.  To  prevent  thi  whenever  i)racti- 
cable  during  the  early  period  of  handling  a  smooth  stylet  dipped  in 
vaselin  should  be  inserted  a  little  way  two  or  three  times  a  day. 

Probing  the  lacrimal  canal  is  resorted  to  mainly  for  ex- 
ploration and  for  rendering  it  patulous  throughout.  It  should  be 
seen  to  that  the  tip  of  the  probe  is  nicely  rounded — in  no  way  sharp 
nor  angular.     The  latter  are  common  faults  with  small  probes. 


Fig.  52. — Probe  of  Bowman.     Plain  tip. 

The  probes  most  commonly  employed  are  those  devised  by  Sir 
Wm.  Bowman  nearly  tifty  years  ago  (Fig.  52).  They  consist  of 
three  double-ended  instruments,  i.e.,  six  probes,  made  of  silver, 
each  bearing  midway  a  shield  to  indicate  the  direction  of  any  bend 
or  curve  that  may  be  given  to  the  probe  while  in  use.  The  shield 
also  bears  the  figures  denoting  the  sizes.  The  diameters  of  those 
of  to-day  are  graduated  by  one-half  millimeter  from  one-half  up 
to  three  millimeters. 

There  are  various  other  forms  of  the  lacrimal  probe,  notable 
among  them  the  series  devised  and  successfully  managed  by  Theo- 
bald, of   Baltimore.     It  comprises  sixteen  instruments  graduated 


122     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

by  one-fourth  millimeters  from  one-fourth  to  four  millimeters. 
Most  eye  specialists  do  not  favor  those  that  exceed  four  or  five 
millimeters.  Whether  the  upper  or  the  lower  route  be  selected 
as  the  better  way  from  punctum  to  sac  would  seem  to  be  largely 


Fig.  53. — Bowman  probe.     Bulbous  tip. 

a  matter  of  individual  choice.  Much  can  be  said  in  favor  of  either, 
though  the  lower  canaliculus  is  favored  by  the  majority  and  is  the 
one  now  in  question.  Bowman's  probes  are  always  serviceable, 
though  the  bulbous  tips  go  best  (Fig.  53). 

The  writer^  employs  a  series  of  gold  sounds  that  he  devised 
several  years  ago,  represented  actual  size  in  the  accompanying  illus- 
tration (Fig.  54),  and  finds  them  both  serviceable  and  easy  of  ma- 
nipulation.    Nos.  I  and  2  it  was  thought  best  to  have  made  of  ten- 


A/°  7 


-o 


/V°J 


A^°<Z 


ORJGINAL  SOUND 
Fig.  54. — Beard's  gold  sounds. 


-o 


carat  gold,  as  this  has  greater  strength,  hardness,  and  elasticity  than 
the  liner  metal,  to  say  nothing  of  the  lesser  cost;  whereas,  Nos.  3 
and  4,  being  of  larger  size,  and  destined  for  other  service — namely, 
only  in  cases  where  Bowman's  operation  has  already  been  per- 
formed are  made  of  fourteen-carat  gold.  The  working  end  of  the 
instrument  is  spindle-shaped  and  is  surmounted  at  the  tip  by  a 
small  guiding  bulb  whose  diameter  is  considerably  less  than  that  of 
the  spindle.  The  diameter  of  the  shaft  is  also  much  less  than  tliat 
of  the  spindle,  and  owing  to  this  fact  the  friction,  instead  of  being 
all  the  way  along,  is  ])ractically  confmed  to  the  enlarged  portion 
only,  yet  the  effect  is  that  of  a  ])robe  of  the  diameter  of  said  en- 
largement; hence,  traumatism  and  discomfort  are  both  minimized. 

■  American  Journal  of  ( )|)luha!mol()gy,  On.,  u;or. 


J5KAKD  S    SOUNDS  I  23 

They  are  especially  useful  for  systemic  Irealment,  as  for  examjjle, 
of  stenosis  from  swollen  lininij;,  from  cicatricial  bands,  etc.,  since  they 
pass  both  backward  and  forward  llu-out^di  llic  narrow  i)la(cs  with 
great  ease,  and  can  be  insinuated  cautiously  and  certainly  into  such 
places  with  the  view  to  local  dilatation.  Indeed,  one  of  the  chief 
advantages  in  the  employment  of  these  sounds  is  one's  ability, 
owing  to  the  peculiar  form  of  the  instrument,  to  feel  along,  as  it 
were,  for  obstructions,  and  thus  to  locate  and  deal  with  them  by 
passing  the  spindle  back  and  forth  through  them — a  ])rocedure  not 
possible  with  rigid  sounds  or  those  that  arc  cylindrical  and  of  uniform 
or  nearly  uniform  diameter  throughout. 

In  the  manufacture  of  these  sounds  the  strictest  attention  should 
be  given  to  minute  de  ail  of  form.  To  mention  a  few  points,  for 
instance,  the  bulb  on  No.  i  and  the  entering  or  guiding  bulb  on 
No.  2  should  not  exceed  3/5  millimeter  in  diameter,  and  both  should 
be  neatly  rounded.  Then,  where  bulb  joins  spindle  and  where 
spindle  joins  shaft,  there  should  never  be  abrupt  curve,  but  one 
part  should  be  made  to  pass  into  the  other  by  almost  insensible 
degrees.  The  size  of  the  spindle  ranges  from  two-thirds  of  a 
millimeter  in  diameter  up  to  two  millimeters.  The  bulbs,  from 
one-third  to  two-thirds  of  a  millimeter,  and  the  length  of  spindles 
from  live  millimeters  for  the  smaller,  to  eight  millimeters  for  the 
larger.  The  shaft,  like  the  tips,  varies  from  one-third  to  two- 
thirds  of  a  millimeter  in  diameter  and  is  eight  centimeters  in  length. 
At  the  distal  extremity  is  a  tiat  shield  or  heart-shaped  plate  by 
which  one  may  always  know  the  direction  of  the  bulb  after  having 
bent  the  shaft  in  any  desired  manner.  As  to  the  wire  for  the  smaller 
sounds,  it  cannot  be  too  springy,  but  ought  not  to  be  of  greater 
thickness  than  2,5  of  a  millimeter;  that  of  Xo.  i  could  well  be  just 
short  of  that.  The  two  smaller  sounds  are  introduced  without 
previous  dilatation  of  the  ])unctum.  No.  3  can  be  used  only 
after  dilatation,  whereas  Xo.  4  '^  employed  in  cases  where 
Bowman's  operation  has  already  been  performed.  The  one  in 
the  illustration  marked  "original  sound"  was  made  from  the 
temple  wire  of  an  old  ])air  of  spectacles,  and  it  was  this  which,  used 
in  an  emergency,  was  the  forerunner  of  this  series  of  sounds. 
The  shield  was  put  on  to  make  it  conform  to  the  others,  and  it  is 
still  of  great  use.  Its  original  spherical  extremity  was  made  oblong 
or  olive,  thus  reducing  its  lateral  diameter. 

To  pass   the  probe  or   sound   through   the   lower  canaliculus, 


124     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

the  punctum  having  been  dilated  or  the  canahculus  slit,  as  the  case 
may  be,  the  position  of  patient,  that  of  the  operator  and  the  holding 
of  the  lid  are  the  same  as  for  dilating  the  punctum.  The  instru- 
ment, previously  greased  with  vaselin,  is  put  into  the  punctum 
vertically,  then  instantly  depressed  to  the  horizontal  and  pushed 
along  the  canaliculus  until  the  end  is  solidly  against  the  lacrimal 
bone.  Here  it  is  held  snugly  while  the  probe  is  again  approached 
to  the  vertical,  hugging  closely  the  brow,  and  pushed  down  into  the 
nasal  or  bony  portion  of  the  canal.  It  is  well  to  remember  that  the 
direction  of  this  portion  of  the  canal  is  downwrard  and  inward,  so 
that  while  hugging  the  inner  wall  of  the  lacrimal  sac  or  bone  with 
the  end  of  the  probe,  throughout  the  elevation  of  the  shaft,  the  in- 
strument should  all  the  while  be  pushed  down  and  in.  Moreover, 
the  elevation  must  be  stopped  short  of  the , perpendicular,  else  the 
tip  may  tend  to  puncture  the  tissues  outside  of  the  lacrimal  fossa 
of  the  nasal  duct  (Fig.  55).  It  was  formerly  taught  that  the 
bony  canals  inclined  the  probes  in  the  opposite  direction,  and  the 
study  of  the  openings  as  found  in  the  average  skull  is  in  favor  of 
this  theory.  Actual  demonstrations  on  the  living  subject  prove 
the  contrary,  notwithstanding,  and  there  can  be  no  question  that 
the  passing  of  the  probe  into  the  nasal  duct  is  facilitated  by  holding 
to  this  view.  Whereas  he  who  adheres  to  the  opposite  belief  and 
inclines  his  probe  to,  or  beyond,  the  median  line,  on  elevating  it 
will  fmd  greater  difficulty  and  will  be  more  apt  to  poke  the  in- 
strument down  into  the  orbit  or  somewhere  external  to  the  lacrimal 
fossa. 

Where  there  has  been  inflammation  of  the  canal,  there  is  most 
apt  to  be  an  abnormal  constriction  just  where  the  canaliculi  meet. 
This  may  be  so  tight  and  solid  as  to  cause  the  belief  thai  the  probe 
has  reached  the  inner  wall  of  the  sac  and  is  ready  to  descend,  which 
would  result  in  a  "false  passage."  Therefore,  when  the  horizontal 
progress  of  the  probe  is  stopped,  if  it  feels  as  if  il  were  against  a 
springy  cushion  or  anything  yielding,  ])arlicularly,  if  on  watching 
the  inner  commissure  of  the  lids,  it  moves  with  the  probe — it  has 
not  entered  the  sac  and  tlic  lid  should  be  lightly  drawn  outward 
and  the  probe  forced,  with  a  drilling  and  oscillating  motion,  till  it 
brings  up  solid  and  firm  before  elevating.  If  a  reasonable  trial  of 
these  means  is  not  attended  witli  success,  it  will  be  necessary  to 
introduce  the  smallest  ])robe-])oinled  knife  and  pusli  it  through  the 
stricture.      (For  method,  sec  Bowman's  o])eration.)     To  withdraw 


PASSIXC-    THK    I'ROBE  I  25 

the  probe,  i)ull  up  and  out,  until  the  li])  has  reached  the  sac,  then 
depress  to  the  horizontal  and  Imish. 

Armaignac,  of  Bordeaux  {La  Cliniquc  Ophthalmologiquc,  July, 
191 1)  has  discovered  a  means  of  greatly  facilitating  the  passage 
of  the  probe  when  there  are  rigid  strictures  to  be  encountered.     He 


Fig.  55. — .Manner  of  passing  lacrimal  probe. 

has  applied  to  catheterism  what  is  used  in  a  machine  for  the  same 
purpose,  viz.,  an  automatic  oiler;  and,  in  the  simplest  possible 
manner,  has  met  with  success.  Before  entering  the  probe  he  in- 
jects into  the  lacrimal  canal,  by  means  of  a  Pravatz  syringe  with  a 
fine  canula,  three  or  four  drops  of  sterile  oilve  oil,  which  fill  the  sac; 


126     OPERATION'S  UPOX  THE  APPENDAGES  OF  THE  EYE 

and,  when  ncci'ssary.  he  makes  slij^ht  ])ressure  on  the  anterior  wall 
in  order  to  get  some  of  the  oil  to  pass  into  the  nasal  duct. 

It  is  surprisint;;,  he  claims,  how  much  this  little  preliminary 
maneuver  aids  the  catheterism.  Strictures,  that  were  unsurmount- 
able  Ijy  former  methods,  allow  the  ])rolje  to  pass  with  an  astonishing 
facility,  without  effort,  and  without  injury  to  the  walls  of  the  canal. 
With  the  same  facility  one  or  two  thicker  numbers  may  be  passed, 
and  during  and  after  the  catheterism  the  pain  is  considerably  dimin- 
ished or  c()mj)letely  sujjjjressed. 

Threading  the  Lacrimal  Canal. — This  refers  to  what  is  said  to 
be  an  effective  manner  of  treating  persistent  dacryocystitis  and  various 
forms  of  stenosis  of  the  canal,  reported  to  the  Ophthalmological 
Society  of  the  Netherlands,  meeting  of  1907,  by  Prof.  Koster. 
This  surgeon  passes  a  silk  thread  through  the  entire  lacrimal  tract, 
makes  a  knot  at  the  upper  end,  or  disposes  of  it  by  sticking  it  to  the 
skin  of  the  lower  lid  to  keep  it  from  entering  the  canal,  coils  the 
lower  portion  and  leaves  it  in  the  nose.  For  the  insertion  of  the 
thread  he  employs  a  series  of  hollow  probes,  of  different  sizes,  each 
having  a  solid  probe  that  passes  easily  through  it.  The  latter  has 
an  eyelet  at  its  distal  extremity.  The  canaliculus  is  slit  open.  The 
hollow^  member  is  passed  into  the  canal  until  its  lower  end  rests 
on  the  floor  of  the  nose,  then  slightly  withdrawn.  The  thread  is 
put  through  the  eyelet  of  the  solid  member,  and  this  is  in  like  manner 
passed  and  left  with  its  threaded  end  touching  the  floor  of  the 
nose.  A  small  blunt  hook  is  used  to  draw  the  thread  out  of  the 
inferior  meatus.  The  thread  is  now  held  while  both  the  solid 
and  the  hollow  probes  are  pulled  out.  By  partially  withdrawing 
the  thread  and  treating  it  with  remedies,  it  is  made  to  serve  as  the 
medium  for  their  application.  The  silk  is  left  in  situ  for  weeks 
or  even  months,  if  need  be.  Here  one  could  probably  fmd  a  sure 
preventive  of  the  persistent  and  rapid  closure  of  the  punctum 
referred  to,  and  avoid  frequent  opening  with  probe  or  stylet,  but 
it  would  be  desirable  to  pass  the  thread  through  the  undivided 
punctum.  In  this  case  the  canula  might  be  dispensed  with  and  a 
very  small  probe  with  an  eyelet  to  carry  fine  thread — say  size  o  or  i, 
— be  used  alone. 

Syringing  the  lacrimal  canal  is  indicated  for  nearly  all  i)]iases 
of  acute  and  chronic  catarrhal  and  su])purative  diseases  to  which 
it    is    subject.     Indeed,  eye  specialists  in    general   are    pretty    well 


LACRIMAL    SYRINGE  1 27 

agreed  that  the  syringe  furnishes  the  best  means  for  the  conservative 
hanclhng  of  these  affections. 

There  are  several  forms  of  syringe  employed  for  the  pur])ose, 
mostly  some  modification  of  the  old  Anel  model.  The  illustration 
(Fig.  56)  shows  one  which  my  colleague  Wilder  and  I  planned  and 
had  made  for  the  staff  of  the  Illinois  Charitable  Eye  and  Ear  In- 
firmary, as  well  as  for  our  private  use.  The  cylinder  is  of  glass 
with  fenestrated  metal  casting  of  nickeled  brass.  The  advantages  of 
a  cylinder  that  enables  one  to  see  its  contents  are  obvious.  The 
piston-head  is  packed  with  asbestos  or  rubber  to  admit  of  boiling, 
and  is  made  to  fit  tight  or  loose  by  turning  the  handle.  The  canulas 
are  made  to  shove,  not  to  screw  on  and  are  of  three  forms.  One, 
conic,  for  forcing  melted  paraffin  or  other  liquid,  as  emulsion  of 
plaster  of  Paris  or  starch,  into  the  sac  to  facilitate  extirpation.  One, 
large  silver  canula  for  use  after  the  canaliculus  has  been  slit, 
the  invention  of  the  late  H.  O.  Tansley,  of  New  York.     This  has 


q;^ 


Fig.  56. — Wilder-Beard  lacrimal  syringe. 

a  blind  tip,  but  its  sides  are  perforated  with  a  number  of  tiny  open- 
ings for  a  distance  of  one  and  a  half  to  two  centimeters  therefrom. 
Lastly,  two  small  silver  ones  for  the  unopened  canaliculus,  of 
equal  diameter,  but  different  as  to  length.  The  tips  of  all  are  made 
smooth  and  rounding.  The  rings  of  the  old  model  are  left  off  both 
barrel  and  piston  and,  instead,  the  head  is  made  projecting  or  flange- 
like, to  afford  a  finger  purchase  and  of  hexagonal  or  octagonal  shape 
to  prevent  rolling  when  laid  down,  while  the  handle  is  in  the  form 
of  a  button.  The  glass  cyhnder  is  fitted  at  either  end  with  a  soft- 
rubber  washer  held  tightly  by  screwing  down  the  heads  of  the  metal 
casing.  The  Tansley  canula  is  a  most  valuable  adjunct  in  cases 
where  Bowman's  incision  has  been  made,  as  it  performs  the 
office  of  a  probe  as  well  as  that  of  a  catheter.  By  its  closed  tip  the 
injected  liquid  is  made  to  wash  or  bathe  the  sides  or  lining  of  the 


128     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

canal,  instead  of  being  shot  straight  through  into  the  nasal  cavity. 
Having  been  once  introduced,  it  may  be  left  in  position  while  the 
syringe  is  disconnected  and  refilled  as  many  times  as  are  desirable 


Fig.  57. — ManiUT  of  usinj^  lacrimal  syringe.     Straight  canula. 

for  thorough  irrigation.     One  must  be  careful  not  to  push  the  nozzle 
of  the  syringe  too  forcibly  into  the  hollow  cone  of  the  canula  for 


SYRINGING    THE    CANAL  120 

such  treatment,  as  they  cannot  be  reachly  scjjaratcd.  The  Tansley 
attachment  is  best  made  with  a  h'ght  curve  and  with  a  shield  or 
facet  on  the  socket  to  indicate  its  (Hrection.  Every  bent  canula 
should  have  such  a  guide. 

To  Syringe  the  Lacrimal  Canal  when  the  Punctum  is 
Intact. — The  positions  of  surgeon  and  subject  are  the  same  as 
for  probing.  The  first  step  is  dilatation  with  the  conical  stylet.  The 
assistant  stands  ready  with  the  loaded  syringe  fitted  with  one  of  the 
smallest  canulas.  The  exchange  of  instruments  is  made  as  descril^ed 
under  "  Dilatation" ;  the  operator  lays  the  barrel  of  the  syringe  across 
the  patient's  nose  so  as  to  point  the  right-angled  curve  of  the  canula 
perpendicularly,  or  nearly  so,  at  the  punctum.  The  syringe  is  held 
between  the  first  and  second  fingers  of  the  right  hand  (for  the 
right  eye)  placed  beneath  the  ring  on  the  barrel,  while  the  thumb  is 
ready  on  the  piston.  It  is  well  to  start  with  such  a  grasp  of  the 
syringe  that  it  will  not  be  necessary  to  make  any  change  therein, 
on  account  of  the  position  of  the  fingers  or  the  direction  of  the 
canula,  until  it  is  emptied.  As  the  stylet  leaves  the  punctum,  the 
tip  of  the  canule  is  slid  in,  at  the  same  time  the  whole  instrument 
is  elevated,  watching  that  the  point  does  not  slip  out  and  holding 
the  lid  slightly  everted  and  stretched  toward  the  temple  throughout 
(Fig.  57).  Now  the  patient  is  made  to  lean  slightly  forward,  to  pre- 
vent the  injection  from  running  into  the  throat,  and  the  piston  is 
pressed  slowly  and  steadily  down  (Fig.  58).  If  there  is  a  feeling  of 
undue  resistance  to  the  descent  of  the  piston,  either  there  is  stenosis 
of  the  canal  or  the  opening  of  the  canula  is  engaged  in  a  fold  of  the 
lining  membrane.  It  is  unwise,  even  dangerous,  then  to  force 
matters,  as  to  do  so  one  risks  the  rupture  of  the  canal  wall  and 
driving  the  liquid,  together  with  infective  secretions,  into  the  sur- 
rounding tissues  and  exciting  suppurative  cellulitis,  with  all  its  dire 
consequences.  In  this  event  it  is  best  slightly  to  withdraw  the  tip 
and  see  that  the  guide  is  right  before  j)rocceding. 

Lacrimal  Stenosis  of  Infants. — It  is  not  uncommon  to  find 
epiphora  and  mucocele  in  the  newly-born  and  in  older  infants.  The 
obstruction  is  usually  in  the  nasal  duct  itself  or  at  its  outlet  into 
the  lower  meatus.  Fortunately,  these  cases  yield  much  more  readily 
to  treatment  than  do  similar  affections  in  older  subjects,  but  the 
remedial  measures  should  be  instituted  as  early  as  possible.  Often 
the  closure  is  merely  epithelial,  and  a  single  passing  of  the  olive- 
tipped  gold  sound,  described  on  page  125,  will  suffice  to  effect  a  cure. 
9 


130     OPERATIONS  UPON 


THE  APPENDAGES  OE  THE  EYE 


Fig.  58. — Miuincr  ul 


usinji  Uuriinal  syrinsi-.     Bi'nt  canul 


HOWMAX  S    OPKRATIOX  17,1 

It  is  ncccssan-,  of  course,  lo  j)ass  ihc  sound  all  llic  way  down  till 
it  enters  the  nasal  ca\ity.  Tiiis  can  be  accomplished  in  most 
instances  under  local  anesthesia,  after  first  (lilatin,<<  the  jjunclum 
and  holding  the  child's  head  between  one'.-,  knees  in  the  regulation 
manner.  Sometimes  a  few  syringings  with  a  mild  antiseptic 
solution  will  be  needed  after  once  the  sound  is  passed. 

Bowman's  Operation;  Incision  or  Slitting  up  of  the  Can- 
aliculus. -Tlie  objects  sought  in  this  ]>rocedure  are  the  evacuation  of 
an  abscess  of  the  lacrimal  sac  that  threatens  to  break  externally,  the 
relief  of  congenital  atresia  or  stenosis  from  traumatism  or  inflamma- 
tory processes,  foreign  bodies,  such  as  short  hairs,  fragments  of 
the  beard  of  grain,  and  the  so-called  dacryoliths,  or  "tear-stones," 
in  the  canaliculi,  and  rarely,  the  dislodgment  of  a  foreign  body 
that  has  entered  the  lower  orifice  of  the  nasal  duct;  to  make  prac- 
ticable the  employment  of  the  larger  probes  and  of  thorough  calhe- 
terism  and  for  curettage  of  the  sac.  Yet  other  indications  are 
sometimes  found,  such  as  eversion  of  the  inferior  punctum  and  new 
growths. 

There  are  three  good  reasons  why  an  abscess  of  the  lacrimal 
sac  should  not  be  permitted  to  rupture  through  the  overlying  in- 
tegument— the  obliterating  adhesion,  the  ugly  scar,  and  the  hazard 
of  a  fistula. 

The  operation  is  not  made  so  often  as  it  formerly  was,  for  the 
reason  that  the  use  of  the  syringe  for  treatment  of  ordinary  dacryo- 
cystitis has  largely  supplanted  the  method  of  systematic  and 
progressive  probing  that  was  once  so  poular.  But  a  single  instru- 
ment is  required,  viz.,  some  one  of  the  various  modifications  of 
the  Weber  canaliculus  knife.  Agnew's  (Plate  1)  is  the  one 
preferred  by  the  writer.  Its  probe  point  has  not  the  long,  slender, 
easily  broken  neck  of  the  Weber  model.  The  edge  of  its  blade  is 
slightly  convex,  which  gives  better  cutting  power  than  if  it  were 
straight,  and  it  has  a  long  shank  of  tough,  malleable  iron  that  can 
be  bent  to  meet  the  exigencies  of  an  overhanging  brow. 

Cocain  or  any  local  anesthetic  is  of  little  value  for  the  opera- 
tion unless  previously  injected  deep  into  the  canal,  and  it  hardly 
justifies  the  use  of  general  anesthesia.  Previous  dilatation  of 
the  punctum  is  unnecessary  and  only  adds  to  the  patient's 
discomfort. 

The  operation  upon  the  lower  canaliculus,  the  one  usually 
chosen,  is  performed  with  patient  and  operator  in  positions  described 


132     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

for  passing  a  lacrimal  probe,  and  the  method  is  much  the  same. 
Given  the  right,  lower  canaliculus  to  incise,  for  instance,  the  napkin- 
covered  head  of  the  patient  is  pulled  back  and  pressed  against  the 
operator's  chest.  The  contents  of  the  sac  are  expressed  when 
possible.  The  knife  is  held  in  the  right  hand.  The  left  thumb  is 
laid  heavily  on  the  right  cheek  or  malar  bone,  for  the  three-fold 
purpose  of  slightly  everting  the  lower  lid,  stretching  it  tightly  toward 
the  temple,  and  fixing  the  patient's  head.  An  assistant  holds  the 
patient's  hands  and  he  is  requested  to  look  upward  during  the  entire 
operation.  The  knife  is  inserted  vertically  at  the  punctum,  then 
lowered  to  the  horizontal,  with  the  edge  looking  upward  and  back- 
ward. Having  proceeded  thus  far,  it  is  good  practice  to  pause  for  an 
instant,  see  that  the  position  of  the  blade  is  just  right,  take  a  firm 
hold  upon  the  handle,  bear  hard  outward  on  the  lid,  to  make  taught 
the  canaliculus,  push  the  knife  straight  inward  until  the  point  stops 
against  the  inner  wall  of  the  sac,  then,  while  holding  it  there, 
bring  up  the  handle,  hugging  the  brow,  through  an  arc  of  ninety 
degrees  or  more,  owing  to  the  length  of  the  cut.  The  plane  of 
the  incision,  instead  of  being  vertical,  is  inclined  toward  the  operator. 
The  extent  of  the  incision  must  be  regulated  by  the  peculiarities 
of  the  case  or  the  end  to  be  attained.  If  this  be  to  admit  of  the  use 
of  somewhat  larger  probes  or  canulse  than  can  be  readily  passed 
through  the  normal  punctum  (a  la  de  Wecker)  the  length  of  the  cut 
need  not  exceed  three  or  four  millimeters;  in  other  words,  an  enlarge- 
ment of  the  punctum.  If  a  greater  opening  is  desired,  the  incision 
may  extend  to  the  caruncle.  According  to  v.  Arlt,  this  means 
about  three-fifths  of  the  length  of  the  canaliculus,  or  it  may  reach 
the  common  duct.  In  no  case,  unless  for  phlegmon  of  that  cavity, 
is  it  advisable  to  extend  a  free  incision  into  the  sac  for  fear  of  per- 
manently disabling  the  internal  canthal  ligament.  If  it  is  desired 
to  pass  the  knife  through  the  whole  length  of  the  lacrimal  canal, 
as  the  handle  nears  the  vertical  the  edge  of  the  blade  is  turned  slightly 
toward  the  front  and  pushed  down  into  the  bony  portion,  as  per 
the  directions  just  given  for  probing.  The  knife  is  brought  out  and 
the  operation  is  finished. 

As  the  kndo  oculi  lies  in  front  of  the  lacrimal  sac,  it  is  quite 
practicable  to  ])ass  the  blade  through  the  sac  and  nasal  duct,  in 
order  to  divide  strictures  without  seriously,  or  at  all,  wounding 
it,  provided  the  edge  is  not  turned  too  much  forward.  In  the  hori- 
zontal progress  of  I  he  knife  tlirough  the  canaliculus,  tlie  anatomy  of 


SLITTING    THE    CAXAI.KULUS  133 

the  parts  must  be  borne  in  mind,  i.e.,  that  the  anterior  half  of 
the  hicrimal  fossa  belongs  to  the  superior  maxilla  and  is  thick  and 
lirm,  while  the  posterior  half  belongs  to  the  thin,  yielding  lacrimal 
bone.  Hence,  if  the  blade  were  thrust  inward  with  great  force, 
unless  it  were  directed  toward  the  anterior  half  of  the  fossa,  it 
could  i)erforate  the  bone  and  enter  the  nasal  cavity. 

Stilling's  practice  of  multiple  division  of  strictures  of  the  deeper 
portions  of  the  canal,  for  which  he  designed  the  knife  that  iK-ars 
his  name,  has  been  supplanted  by  systematic  and  graduated  probing. 
Stricturotomy,  as  a  prelude  to  forced  dilatation  of  both  the  mem- 
branous and  the  bony  portions  of  the  lacrimal  canal,  however,  is 
still  extensively  practiced. 

The  correct  location  for  the  slit  is  in  the  posterior  superior  wall 
of  the  canaliculus,  hence  the  necessity  for  directing  the  knife  with 
edge  slightly  backward.  Were  it  along  the  top  or  superior  wall,  it 
would  be  unsightly  and,  worse  still,  the  function  of  this  part  of  the 
canal  would  be  destroyed.  Even  when  placed  in  the  most  favorable 
position  possible,  be  it  long  or  short,  this  incision  greatly  interferes 
with  the  drainage  of  the  conjunctival  sac.  The  suction  of  the 
lacrimal  sac,  caused  by  the  alternate  contraction  and  relaxation 
of  the  orbicularis  and  Horner's  muscle,  through  nictitation,  is 
spoiled  by  the  slit,  and  this  alone  is  a  frequent  cause  of  epiphora. 
The  fact  that  gravity  puts  the  burden  of  draining  of  the  conjunctival 
sac  mainly  upon  the  lower  canaliculus  is  a  strong  argument  in 
favor  of  slitting  the  upper  one  and  preserving  the  lower  whenever 
practicable. 

Should  the  surgeon  prefer  to  wield  the  knife  with  the  right  hand 
for  both  eyes  and  the  left  canaliculus  is  to  be  divided,  an  assistant 
stands  behind  the  patient  to  hold  the  head,  and  the  operator  in 
front.  Otherwise  it  is  behind  for  the  right  eye  and  in  front  for 
the  left.  The  rest  of  the  method  is  the  same  as  for  the  right  eye, 
save,  of  course,  that  the  inclination  of  the  cut  is  away  from  the 
operator.  In  making  the  operation  upon  either  of  the  upper 
canaliculi,  as  also  in  dilating  and  probing  them,  the  surgeon's 
position,  be  he  ambidextrous  or  not,  is  in  front  of  the  patient, 
for  both  eyes.  It  goes  without  saying  that  the  inclination  of 
the  blade  or  the  position  of  the  slit  is  here  backward  and 
downward. 

Bandaging  is  not  required  after  slitting  of  the  canaliculus. 
The  subsequent  care  of  the  case  comprises  merely  bathing  with 


134     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

\-crv  hoi  water  or  antisL'])tic  washes  and  the  appropriate  use  of  sound 
or  syrins^e. 

Removal  of  a  triangular  section  of  the  posterior  wall  of  the 
lower  canaliculus,  as  first  practised  by  Critchett,  of  London,  for 
cversion  of  the  punctum,  with  epiphora,  seems  to  have  fallen  into 
disuse.  This  consisted,  first,  in  slitting  up  the  canaliculus  as  far  as 
the  caruncle,  in  the  usual  way.  Second,  a  vertical  snip  with  scissors, 
extending  down  two  or  three  millimeters  from  the  punctum,  on  the 
inner  aspect  of  the  lid.  Third,  the  joining  of  this  with  the  inner 
end  of  the  first  incision,  or  the  resection  of  the  triangle  thus  formed. 
The  idea  was  that  the  secretions  of  the  eye  would  thus  be  provided 
with  an  open  drain.  In  effect,  it  proved  to  be  a  delusion,  as  lacrimal 
drainage  is  not  accomplished  through  gravity.  Moreover,  such  a 
piling  up  of  conjunctival  growth  took  place  about  the  site  of  the 
operation  as  to  effectually  block  any  sort  of  outiiow.  Arlt  pro- 
duced a  form  of  epicanthus  to  relieve  epiphora  in  cases  of  eversion 
of  punctum  where  the  orbicularis  was  paretic. 

In  closing  this  subject,  there  is  one  injunction  the  observance  of 
which  cannot  be  too  strongly  insisted  upon,  viz.,  as  a  rule,  avoid  the 
use  of  the  syringe  immediately  after  that  of  the  probe  or  knife.  This  is 
to  prevent  the  unpleasant  or  serious  results  of  forcing  the  injected 
liquid  into  the  cellular  tissue.  This  rule  may  be  departed  from  in 
cases  that  are  famihar  because  of  a  number  of  previous  probings 
where  the  passing  of  the  instrument  has  been  such  as  to  insure 
freedom  from  traumatism,  but  the  syringing  should  be  done  very 
cautiously.  When  probe  and  syringe  are  both  to  be  employed  in 
a  given  case,  if  practicable,  the  probe  should  follow  the  syringe. 
If  not,  it  were  better  to  let  at  least  twenty-four  hours  elapse  be- 
tween the  two  acts. 

Incisions  of  the  anterior  exterior  wall  of  the  lacrimal  sac 
have  been  made  in  cases  of  dacryocys  oblcnorrhea,  for  curetment. 
as  when  that  portion  of  the  Iractus  is  tilled  with  granulations, 
to  give  access  to  the  cautery  for  its  obliteration,  and  for  the  evacua- 
tion of  ])us  in  phlegmonous  inllammation.  Opening  of  the  anterior 
wall  <jf  the  sac  is  done  after  the  following  manner:  for  the  right 
side  an  assistant  holds  the  j)atient's  head,  as  in  slitting  the  upper 
canaliculus.  The  operator  stands  in  front.  The  third  linger  of 
the  left  hand  is  placed  on  the  skin  at  the  outer  commissure  of  the 
lids  and  the  palpebral  fissure  is  stretched  outward,  while,  with  the 
index,   the   tendo  oculi   is   located.     A  sharp  bistoury  or  Beer's 


INCISION    OF    ANTERIOR    WALL  135 

knife  is  held  penholder  fashion  in  the  right  hand,  edge  downward. 
The  point  is  placed  just  bencalh  the  middle  of  the  inner  canthal 
ligament,  with  the  handle  leaning  slightly  toward  the  temple. 
The  blade  is  then  jnished  back,  in,  and  slightly  down,  until  the 
point  touches  the  bone  at  the  posterior  wall  of  the  sac.  The  knife 
is  now  withdrawn,  extending  the  outer  wound  slightly  downward 
and  outward,  taking  care  not  to  cut  the  posterior  wall  of  the  sac. 
The  incision  may  be  extended  to  any  desired  length,  by  means  of 
a  blunt,  curved  bistoury,  blunt  scissors  or  even  a  Weber  canaliculus 
knife.  For  upward  lengthening,  scissors  are  preferable,  the  outer 
blade  being  placed  beneath  the  tendo  oculi  and  the  inner  one,  in  the 
sac.  To  get  at  the  interior  of  the  sac,  the  wound  is  held  open  by 
retractors,  the  MuUer  Speculum,  or  simple  strabismus  hooks. 

There  is  apt  to  be  considerable  hemorrhage,  so  much,  in  fact, 
that  where  the  sac  is  to  be  obliterated  by  the  cautery,  many  opera- 
tors have  chosen  to  make  the  operation  in  two  sittings.  At  the 
first  the  opening  is  made,  the  cavity  packed  with  gauze,  dressing 
appHed  and  left  thus  for  twenty-four  hours.  At  the  second,  the 
cautery.  In  this  way  the  walls  of  the  sac  are  dry  and  in  the  best 
possible  condition  for  the  finishing  process.  One  may  choose 
between  the  thermic  cautery — as  the  galvano  or  Paquelin — and 
the  chemic,  as  the  nitrate  of  silver  or  mitigated  sdck. 

Relatively  few  modern  surgeons,  however,  have  recourse  to  the 
incision  of  the  anterior  exterior  wall  of  the  lacrimal  sac,  preferring 
extirpation  for  the  first  tw^o  conditions  and  the  slitting  of  the  canal- 
iculus for  the  third.  This  last  demands  a  complete  section  from 
punctum  to  sac  or,  at  least,  to  the  common  duct  and,  in  addition, 
the  subsidiary  passage  of  the  knife  through  the  nasal  duct,  as  al- 
ready described.  This  is  followed  by  expression  of  the  pus  by  way 
of  canaliculus  or  nose.  Agnew^  of  New  York,  preferred  the  canal- 
iculus or  conjunctival  incision  to  the  external  or  cutaneous  one, 
even  to  get  at  the  sac,  for  its  obliteration.  Others,  as  A.  Tersen^ 
for  example,  for  curettage  of  the  sac,  first  slit  the  upper  canaliculus 
and  then  made  use  of  his  slender,  curved,  fenestrated  curet  (Fig. 
59).  Many  and  valid  objections  to  this  sort  of  treatment  at  once 
present  themselves. 

The  immediate  after-treatment  consists  in  frequent  bathing  with 
hot  water.  The  water  is  previously  boiled  and  is  applied  as  hot  as 
can  be  tolerated  by  the  skin  by  means  of  pieces  of  gauze  or  wads  of 

'  Bull,  ct  ]Mem.  Soc.  franc    d'opht.,  1893. 


136     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

absorbent  cotton.  The  patient  sits  erect  and  holds  beneath  his 
chin  a  bowl,  containing  the  water,  which  he  dabs  on  continuously 
for  only  a  few  minutes  at  a  time.  There  can  be  no  objection  to 
making  the  liquid  into  a  mild  antiseptic  solution.  After  twenty- 
four  to  thirty-six  hours,  daily  or  twice-daily  syringing  is  begun. 
For  this  the  Tansley  blind-ended  canula  and  a  twenty-live  to  fifty 
per  cent,  solution  of  argyrol  are  most  commendable. 

Sealing  of  the  puncta,  by  touching  them  with  the  electric 
cautery,  in  cases  characterized  by  discharge  from  the  lacrimal 
canal  as  a  preliminary  to  such  operations  as  extraction  and  iridec- 
tomy is  sometimes  done.  After  the  danger  of  infection  has  passed, 
if  the  openings  are  not  re-established  by  sloughing  out  of  the  eschar. 


Fig.  59. — Terson's  curet. 

dilatations  with  the  stylet  of  Landolt  may  be  instituted.  Haab  once 
advised,  for  the  above  purpose,  inserting  a  slender  electrode  into 
the  canaliculi  for  a  distance  of  five  or  six  millimeters  and  searing 
the  mucous  membrane.  Rather  a  drastic  step  unless  attended 
with  extirpation  of  the  sac,  in  which  event  it  would  serve  to  make 
the  operation  complete. 

Ligation  of  both  canaliculi,  first  proposed  by  Quackenboss  and 
later  by  Buller,i  of  Montreal,  or  of  the  common  duct,  as  practised 
by  the  writer,  preparatory  to  operations  that  necessitate  opening  of 
the  eyeball  is,  perhaps,  next  to  the  radical  procedure  of  absolute 
removal  of  the  sac  and  the  fiery  obliteration  of  the  canaliculi,  the 
best  means  of  preventing  infection  from  the  lacrimal  canal.  Some 
operators  advise  tying  of  each  canaliculus  separately,  but  a  single 
ligature  applied  to  both  is  better.  It  is  advisable,  for  example, 
when  extraction  is  to  be  made  and  there  exists  a  state  of  the  tear 
passage  that  would  endanger  the  result  and  which,  from  lack  of 
time,  the  patient's  consent,  or  other  cause,  it  would  be  impracticable 
to  remove.  The  time  for  the  operation  is  the  moment  preceding 
the  extraction,  and  it  is  performed  in  the  following  manner:  the 
contents  of  the  sac  and  canaliculi  are  thoroughly  expressed.  The 
canal  may  be  syringed  with  a  mild  antiseptic  wash.  Wood,  of 
Chicago,  mentions  having  previously  injected  a  solution  of  argyrol, 

'  Montrc-al  Mud.  Jour.,  Mar.,  1902. 


ELECTROLYSIS    OF    DUCT  137 

letting  remain  what  would.  Two  No.  i  Bowman  probes  are 
passed  into  the  sac— one  through  the  upjjer,  the  other  through  the 
lower  canaliculus— and  held  there  by  an  assistant,  as  guides.  They 
are  held  somewhat  apart,  so  as  to  mark  the  outermost  bounds  of  the 
canal  above  and  below.  A  half-curved  needle  of  small  dimensions, 
armed  with  No.  2  or  3  silk  thread  is  passed  in  just  below  -the  lower 
probe,  and  close  to  the  inner  canthus,  deep  enough  to  clear  the  union 
of  the  canaliculi  at  the  back,  and  out  just  above  the  upper  probe, 
and  securely  tied.  The  fibres  of  the  tarsal  ligament  are  necessarily 
included,  and  so  much  the  better,  as  they  assist  in  the  compression 
of  the  canal.  Braided  silk  thread,  boiled  in  paraffin,  makes  a 
more  suitable  ligature  than  cat-  or  silkworm  gut,  as  it  is  not  so  harsh 
and  irritating  to  the  skin  and  does  not  work  loose.  It  is  best  not 
to  leave  it  double,  i.e.,  both  strands  in  unless  it  is  doubled  and 
twisted  after  having  been  put  through  the  eye  of  the  needle.  The 
ligature  may  be  removed  in  four  or  five  days  or  after  sufficient 
healing  of  the  corneal  section.  If  there  is  any  resulting  stenosis 
of  the  canal,  which  is  not  likely,  it  can  be  relieved  afterward  by 
dilating  the  punctum  and  passing  a  small,  olive-tipped  probe. 

Electrolysis  of  the  Nasal  Duct.—We  all  have  cases  of  epiphora 
in  which  the  chief  or  sole  obstruction  to  drainage  is  an  obstinate 
stenosis  of  the  bony  portion  of  the  canal.  Usually,  by  applying 
great  force,  a  small  probe  will  pass  into  the  nose,  but  each  time  it 
is  almost  like  making  an  opening  through  bony  tissue.  Stricturotomy 
is  useless  or  worse.  Here  is  where  electrolysis  finds  an  application. 
Indeed,  we  have  here  a  form  of  operative  treatment  that  will  often 
enable  us  to  relieve  obstinate  epiphora,  and  in  a  surprisingly  short 
time,  when  nothing  else  would  be  of  any  avail.  The  toughest 
strictures  seem  to  melt  like  wax  before  the  electrically  charged  sound. 
For  a  description  of  the  method  and  the  instrument,  I  here  give  a 
translation  from  Baudry.^ 

"Preliminary  Dilatation  of  the  Lower  Punctum  with  the 
Conical  Stylet.— An  antiseptic  injection  is  useful  to  disinfect  the 
field  of  operation.  A  convenient  supply  of  electricity  is  necessary. 
The  electrolytic  sound  of  Lagrange  (Fig.  60),  No.  i  or  2,  is  passed 
into  the  nasal  canal.  The  upper  part  of  this  sound  is  covered  with  a 
casing  of  non-conducting  material,  to  protect  the  canaliculus  and 
sac,  while  the  lower  ])ortion,  uninsulated  for  a  distance  of  two 
centimeters,   is   in  contact   with   the  nasal  canal.     The  sound   is 

'"Tecliniquc  Operaloirc,"  1902. 


138     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

connected  with  the  negative  pole  of  a  battery  furnished  with  the 
galvanometer  aperiodique  (of  Chardin)  or  any  practical  one,  the 
positive  electrode  being  inserted,  wrapped  in  a  wad  of  cotton,  satu- 
rated with  salt  solution,  in  the  inferior  meatus  of  the  nose,  and  held 
immovable.  The  current  is  regulated  by  a  rheostat  (Bergonie's  is 
mentioned).  The  current  passes  slowly  and  steadily  from  nought 
up  to  5  milliamperes,  remains  at  this  for  three  to  five  minutes, 
then  returns  again  by  insensible  degrees  to  naught. 

These  sittings,  which  are  not  at  all  painful,  are  repeated  two, 
three,  or  four  times,  according  to  the  case.  As  soon  as  the  sound  is 
removed,  another  antiseptic  injection  is  made." 


Fig.  60. — Sound  of  Lagrange. 

Extirpation  of  the  Lacrimal  Sac— This  is  a  comparatively 
recent  surgical  measure.  True,  nearly  two  hundred  years  ago 
Planter  tried  an  excision  of  the  sac  combined  with  an  attempt  to 
establish  a  permanent  fistula  connecting  the  conjunctival  sac 
with  the  nasal  cavity,  a  form  of  operation  that  has  been  recently 
revived.  Little  was  done  in  the  way  of  actual  removal  of  the  sac, 
even  following  Berlin's  important  paper  on  the  subject  at  the 
Heidelberg  Congress  of  1868,  till  within  the  past  25  years.  During 
this  period  the  procedure  has  gained  advocates  in  a  sort  of  arithmeti- 
cal progression.  There  are  two  routes  by  which  the  sac  is  got  at, 
one  by  way  of  the  conjunctiva,  or  the  mucous,  the  other  by  way 
of  the  skin,  or  the  cutaneous.  In  the  last  decade  the  first  has 
practically  given  way  to  the  second. 

Mucous  Route. — Probably  a  fair  reprcscnlativc  of  this  class  is 
the  method  of  Van  Hoffmann,  contributed  to  the  Heidelberg 
Congress  of  1896.  The  first  step  consists  in  slitting  up,  after 
Bowman,  of  both  canaliculi,  which  are  then  carefully  dissected  out 
their  entire  length,  or  as  far  as  their  common  duct.  The  loosened 
canaliculi  are  grasped  by  broad-jawed  forceps  and  drawn  forward, 
while  the  incisions  made  in  slitting  them  are  joined  by  separating 
skin  from  conjunctiva  around  the  inner  canlhus.  This  makes  an 
opening  from    punclum  lo   punclum,   or  one  about  12  mm.  long. 


EXTIRPATION    OF    SAC  139 

Through  this  one  works  carefully  inward,  between  canthal  ligament 
in  front  and  Horner's  muscle  behind,  to  expose  the  body  of  the  sac. 
Having  freed  this  front  and  back,  it  is  pulled  downward  and  the 
dome  is  dissected  around.  The  whole  is  then  pulled  out  at  the 
wound,  while,  witli  blunt  dissection,  the  sac  is  loosened  from  its 
bony  bed.  Lastly,  when  only  the  nasal  portion  remains  fast,  this  is 
severed  with  small  blunt-pointed  scissors,  as  low  down  as  possible, 
strong  traction  being  meantime  made  upon  the  sac.  The  only 
points  claimed  in  favor  of  the  mucous  route  are  freedom  from 
excessive  bleeding,  and  absence  of  visible  scar.  When  one  con- 
siders how  little  these  figure  in  the  most  ai)])roved  cutaneous 
route,  and  i)uts  this  against  the  difikulties  and  inconveniences 
of  the  mucous  route,  the  advantages  are  mainly  on  the  side  of 
the  former. 

Cutaneous  Route. — The  form  of  extirpation  here  alluded  to 
is  that  first  done  by  von  Graefe,  in  which  the  sac  is  removed 
without  intentional  incision  of  its  walls,  except  at  the  entrances  of 
the  common  and  the  nasal  ducts,  and  is,  by  the  writer  at  least, 
preferable  to  that  form  by  which  the  anterior  wall  is  opened  before 
dissecting  out  is  begun.  Seeing  that,  in  order  to  be  most  com- 
plete and  successful,  not  only  the  sac,  but  also  the  canaliculi  and  the 
lining  of  the  nasal  duct  should  be  removed,  the  operation  would 
better  be  called  "extirpation  of  the  lacrimal  canal." 

There  is  considerable  diversity  of  opinion  among  ophthalmic 
surgeons  both  as  to  the  indications  for  this  operation  and  as  to 
its  gravity.  The  elder  Knapp,^  for  instance,  considers  it  too  radical 
a  measure  to  be  resorted  to  unless  other  modes  of  treatment  have 
failed.  Among  these  he  even  numbers  the  repeated  openings  of  the 
anterior  wall  and  thorough  cauterization— extending  over  weeks 
and  months— because  they  are  less  terrible  to  the  patient  and  freer 
from  the  dangers  of  suppuration  and  orbital  cellulitis.  Whereas, 
the  younger  Knapp-  considers  the  operation  much  less  formidable 
and  resorts  to  it  often,  as  in  chronic  suppuration  of  the  canal  that 
does  not  yield  readily  to  antiseptic  treatment  in  recurrent  abscess, 
in  dilatation  of  the  sac,  whether  the  contents  can  be  expressed  or 
not,  and  in  lacrimal  fistula.  The  operation  is  undoubtedly  grow- 
ing in  popularity,  and  the  indications  for  making  it  are  broadening 
more  and  more.     It  may  be  confidently  asserted  that  it  a  fiords  the 

'  Norris  and  Oliver,  "  System,"  pp.  902  and  903. 
-  Arch,  of  Oph.,  July,  1903. 


I40     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

quickest,  surest  and  most  satisfactory  means  of  curing  most  of  the 
really  bad  chronic  cases.  The  epiphora,  while  it  persists  for  a  short 
time  after  the  operation,  ultimately  ceases  in  the  vast  majority  of 
instances. 

Indications.— Among  these  may  be  classed  all  those  trouble- 
some affections  of  the  lacrimal  passage'in  which  more  conservative 
methods  either  cannot  or  may  not  be  effectively  carried  out,  such  as 

1.  Chronic  dacryocystitis  with  mucocele  and  excessive  distention 
of  the  sac. 

2.  Chronic  suppuration  of  the  canal  with  recurrent,  phlegmonous 
inflammation,  or  caries  of  neighboring  bony  structures,  or  fungosi- 
ties,  and  with  or  without  fistula. 

3.  Incurable  obliteration  of  some  portion,  as  of  the  nasal  duct, 
through  disease  or  traumatism,  with  troublesome  epiphora. 

When  the  status,  as  per  either  of  the  first  two  classifications  is 
present,  some  form  of  quick  riddance,  either  by  obliteration  or 
extirpation,  becomes  imperative  under  the  following  conditions, 
viz. :  (i )  If  an  operation  that  necessitates  the  cutting  into  the  globe, 
wounding  of  the  cornea,  or  opening  of  Tenon's  capsule  is  demanded 
for  the  eye  which  is  involved,  as,  for  examples,  extraction,  pter- 
ygium, strabismus  and  enucleation.  (2)  If  there  exists,  on  the  side 
of  the  diseased  lacrimal  passage,  a  defect  of  the  cornea  that  renders 
it  peculiarly  vulnerable  to  infection,  such  as  an  ulcer,  a  cystoid 
cicatrix,  or  partial  staphyloma.  (3)  If  the  patient  is  or  is  soon  to 
be  so  circumstanced  that  prolonged  conservative  treatment  is  out 
of  the  question. 

Extirpation  is  usually  done  under  complete  narcosis,  though  I 
have  frequently  made  the  operation  without  an  anesthetic,  with 
comparatively  little  inconvenience  to  the  patient  and  very  decided 
advantage  to  the  operator.*  Anesthesia,  by  the  Schleich  process  I 
do  not  approve  of,  for  it  interferes  with  that  nice  differentiation  of 
tissue  that  is  one  of  the  greatest  requirements  for  the  success  of 
such  surgery.  Cocain  solution  put  into  the  opening  is  useless 
for  the  relief  of  pain,  and  worse  than  useless  because  of  its  effect  on 
the  blood-vessels. 

Following  the  lead  of  those  who  inject  solidifying  solutions  into 
the  sac  I  have,  in  a  few  instances,  tried  with  satisfaction  the  filling 
of  the  sac  with  melted  paraffin  (Wilder)  that  congeals  at  a  temperature 
considerably  higher  than  that  of  the  body — say  at  110°  to  120°  F. 

'  See  Miiller's  Method,  ]>.  14S. 


INJECTIONS    INTO    THE    SAC  I4I 

To  obviate  too  free  entrance  of  the  parairin  into  the  nose  and  throat 
it  should  not  be  too  hot,  but  somewhat  thick — like  cold  molasses. 
Where  degenerative  changes  in  the  wall  have  not  been  too  great, 
the  difficulties  attendant  upon  the  shelling  out  of  sac  are  appreciably 
lessened  by  having  it  thus  made  into  a  firm  tumor.  One  of  our 
internes,  recently  serving  in  the  Illinois  Eye  and  Ear  Infirmary, 
Dr.  Fullenwider,  suggested  the  use  of  fine,  dental  plaster  which 
seems  to  answer  yet  better  than  the  paraffin.  Those  substances, 
the  paraffin  melted  (previously  boiled)  and  the  plaster,  made  into 


Fig.  61. — Broeckaert  paraffin  injector. 

a  thin  emulsion  with  sterilized  water  to  which  a  little  salt  is  added, 
are  injected  through  the  dilated  punctum  by  means  of  the  syringe 
described  on  page  127,  using  the  conical  canula.  C.  R.  Holmes, 
of  Cincinnati,  uses  a  thick  paste  of  starch  colored  with  iodin,  and 
Valude,  of  Paris,  has  recommended  spermaceti.  One  must  be 
careful  not  to  use  undue  force  in  the  performance,  else  a  rupture 
will  occur  and  the  material  be  driven  into  the  adjacent  tissues. 
Should  this  occur  in  the  use  of  a  non-absorbable  material  and  steps 
be  not  at  once  taken  to  remedy,  either  a  permanent  deformity  or  a 
subsequent  operation  will  be  the  result.  Therefore,  if  the  surgeon 
is'aware  of  such  an  accident  before  closing  the  external  incision, 


142 


OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 


ihe  material  should  be  dissected  out.  The  patient  should  be  prone 
upon  his  back  and  all  ready  for  the  operation  of  extirpation.  The 
inferior  nasal  meatus  is  tamponed  with  vaselined  cotton  to  prevent 
blood  or  other  fluid  from  entering  the  nose,  throat,  and  larynx. 

All  pus  or  other  fluid  is  first  thoroughly  expressed  from  the  sac  and 
canaliculi,  the  cavity  washed  out  and  the  liquid  again  expressed. 
If  paraflin  is  put  in,  it  is  then  hardened  by  applying  crushed  ice  or 
a  cooling  spray,  as  of  chlorid  of  ethyl,  to  the  overlying  skin.  If 
plaster,  a  few  minutes  is  given  for  it  to  set.  This  throwing  in  of  a 
hardening  substance  serves  to  make  a  mould  not  only  of  the  sac, 
but  also  of  the  canaliculi,  and  does 
away  with  the  need  of  inserting  probes 
for  purposes  of  orientation.  Prob- 
ably a  less  uncertain  method  of  fill- 
ing the  sac,  and  one  as  well  calculated 
to  facihtate  the  extirpation,  is  that  of 
Jocqs,  of  Paris,  which  consists  in 
making  a  small  opening  in  the  ante- 
rior w^all  as  soon  as  the  sac  is  reached 
and  packing  the  entire  organ  with 
absorbent  cotton.  Another  feasible 
plan  is  to  fill  the  sac  with  cold  par- 
affin, of  relatively  low  melting-point, 
by  means  of  one  of  the  powerful  in- 
jectors made  for  that  purpose  (Figs. 
6i  and  62). 

One  of  the  good  points  mentioned 
by  Czermak  in  this  connection  is  the 
occlusion  of  the  lids  during  the  oper- 
ation in  purulent  cases  with  strips  of 
adhesive  plaster.  He  reasons  thus:  through  the  action  of  the  re- 
tractors in  holding  open  the  wound,  the  palpebral  fissure  gapes, 
the  corneal  epithelium  dries  and  exfoliates  or  cracks,  and  discharge 
from  the  puncta  coming  in  contact  with  it  might  result  in  serious 
infection.  This,  of  course,  would  prevent  the  use  of  probes  passed 
into  the  sac  as  guides. 

Anatomical  Notes. — The  inferior  nasal  quadrant  of  the  orbital 
rim  is  formed  by  a  sharp  ridge  on  the  nasal  process  of  the  superior 
maxillary  bone.  Midway  of  this  ridge  is  a  prominent  convexity 
which   is  the  aulcrior  lacrimal  crest.     Immediately  behind  this  is 


Fig.  62. 


-Bcck-Muller  paraflm 
injector. 


EXTIRPATION    OF    TIIK    SAC 


143 


the  lacrimal  groove  or  thai  portion  of  the  latrinial  fossa  belonging 
to  the  superior  maxilla.  The  other,  or  posterior  part  of  the  fossa, 
is  formed  from  the  delicate  lacrimal  bone,  and  is  bounded  at  the 
back  by  a  slight  ridge — the  posterior  lacrimal  crest.  'J'he  fossa  ends 
below  in  a  short,  round  bony  canal,  leading  to  the  inferior  meatus 
of  the  nose.  Fossa  and  canal  lodge,  respectively,  the  lacrimal  sac 
and  the  nasal  duct  (see  Fig.  63).     A  sharp  oval  is  marked  on  the 


Fig.  63 


[,  Anterior  lacrimal  crest.      2,  Lacrimal  gro()\e 
lacrimal  crest.     4,  Attachment  of  tendo  ocul 


,S,  I'oslerior 


drawing  to  show  the  place  of  attachment  of  the  anterior  branch  of 
the  tendo  oculi,  or  internal  canthal  ligament.  This  branch  is  bifid,  one 
prong  for  each  tarsus.  Back  of  this,  with  only  thin  fascia  intervening, 
is  the  upper  extremity,  or  cupola  of  the  lacrimal  sac  (see  Fig.  64), 
behind  which,  likewise,  is  the  posterior  branch  of  the  tendo 
oculi,  and  behind  that  is  the  muscle  of  Horner.  The  last  two 
are  attached  to  the  posterior  lacrimal  crest.  Separating  this 
whole  mechanism  from  the  deeper  structures  of  the  orbit  is  a 
stronger  fascia,  the  septum  orhitale.      The  opening  of  the  united 


144 


OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 


canaliculi  is  seen  between  the  branches  of  the  tendo  ocuh.  The 
cupola  of  the  lacrimal  sac  rises  to  about  the  level  of  the  upper  edge 
of  the  tendo  oculi.  Fig.  65  shows  the  arrangement  of  the  blood- 
vessels of  this  vicinity.  This  drawing  makes  clear  why  the  incision 
should  not  lie  to  the  nasal  side  of  the  rim  of  the  orbit;  and  why 
one  should  be  careful,  in  loosening  the  cupola,  lest  copious  bleeding 
be  caused  l)y  wounch'ng  the  vessels  that  connect  the  facial  and  the 


Fig.  64. — I,  Anterior  branch  of  tendo  oculi.     2,  Lacrimal  sac.     3,  Posterior  branch 
of  tendo  oculi.     4,  Horner's  muscle.     5,  Septum  orbitale. 

ophthalmic  systems.  Different  subjects  vary  greatly  as  to  the 
depth  at  which  lies  the  lacrimal  sac. 

Position  of  Operator. — ^This  may  be  a  matter  of  individual 
preference,  but  the  writer  has  found  that  he  can  work  to  much  better 
advantage  if  he  stands  at  the  side  of  the  table,  instead  of  at  the  head; 
and  on  the  same  side  as  is  situated  the  eye  to  be  opcrated^right 
side  toward  the  table  for  the  right  eye,  and  vice  versa. 

The  Technic. — First  step. — With  a  convex-edged  scalpel  an 
incision  is  made  over  the  sac,  beginning  just  beneath  the  tendo 
oculi  and  extending  about  two  and  one-half  centimeters  down  and 
out,  following  the  natural  sulcus  that  marks  the  infcronasal  rim  of 
the  orbit  (Fig.  66).     In  case  the  subject  is  one  of  those  in  whom  the 


EXTIRPATION    OF    THF.    SAC 


f45 


sac  is  not  deeply  situated  a  shorter  incision  would  suffice,  but  there 
is  no  drawback  to  one  of  the  length  here  specified,  and  the  task 
is  perceptibly  lightened  by  having  a  generous  opening.  So  situ- 
ated, the  incision  avoids  the  larger  blood-vessels — i.e.,  the  branches 
of  the  facial  artery  and  vein  called  angular — and  the  scar  is  least 
conspicuous.  The  tissues  are  deliberately  divided,  layer  by  layer, 
first  the  skin,  second  superficial  fascia,  third  orbicularis,  and  fourth 


Fig.  65. — I,  Supra-orbital  artery  and  vein.  2,  Nasal  artery.  3,  Angular  artery. 
4,  Facial  artery.  5,  Infra-orbital  artery.  6,  Branch  of  superficial  temporal  artery. 
7,  Malar  branch  of  transverse  artery  of  the  face.  8,  Superior  palpebral  artery. 
9,  Anastomoses.  10,  Inferior  palpebral  artery.  11,  Facial  vein,  12,  Angular  vein. 
13,  Branch  of  superficial  temporal  vein.  14,  Lacrimal  sac.  15,  Internal  canthal 
ligament.  15',  External  canthal  ligament.  16,  Lacrimal  artery.  17,  Ligament  of 
the  tarsus.     18,  Tarso-orbital  fascia. — {After  Testut.) 

the  deeper  fascia,  so  as  to  come  with  discrimination  down  onto 
the  anterior  w^all  of  the  sac,  and  keeping  all  the  while  close  in  behind 
the  anterior  lacrimal  crest.  Caution  is  required  in  dividing  the  last 
layer  or  the  sac  may  be  opened.  Diligent  sponging  is  kept  up  and 
the  lips  of  the  deepening  and  broading  wound  are  held  well  apart 
by  squint-hooks  or  Desmarre's  retractors,  or  if  an  assistant  is  not 
available,  by  Miiller  or  Eversbusch  speculum  (Fig.  67). 

Second  step. — When  the  smooth,  red  membrane  composing  the 
offending  organ  is  exposed,  blunt  dissection  or  very  careful  cutting 
around  with  dull-pointed  scissors  is  begun:   first,  loosen   the  outer 


146 


OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 


or  lateral  side,  then  the  inner  or  median  side,  then  the  back,  which 
lies  deep  in  its  fossa,  then  up  about  the  cupola.  The  shelling-out 
of  the  sac  is  greatly  facilitated  by  passing  a  strabismus  hook  behind 
it  as  soon  as  its  body  is  exposed.     This  can,  by  alternately  pulling 


I'iG.  66. — Incision  for  lacrimal  extirpation.     After  the  incision  is  open 
the  whole  is  retracted  and  drawn  upward  and  inward. 

gently  upon  it  and  working  it  up  and  down,  be  made  to  assist 
materially  in  the  loosening  process.  Scrupulously  avoid  cutting 
the  sac,  the  canaliculi,  the  tendo  oculi,  the  inferior  oblique  muscle,  or 
making  an  opening   in  the   tarso-orhital  fascia  or  septum  orbitale. 


Retractor  of  Eversh 


This  last  is  about  the  gravest  accident  that  could  happen  during 
the  operation  in  question,  as  it  could  lead  to  septic  cellulitis  of  the 
orbit,  to  loss  of  sight  through  necrosis  of  the  cornea,  or  through 
strangulation  of  the  optic  nerve,  or  infection  of  the  choroid,  or 
to  death   itself,  bv  ascending  meningitis   or    bv   thrombo-plilebitis 


EXTIRPATIOX    OF    TlfF.    SAC 


M7 


of  the  sinuses  of  the  dura.  Should,  hy  any  chance,  a  wound  be 
made  in  this  fascia,  the  o])enin,L!;  should  l)e  thoroui^dily  disinfected 
and  tightly  closed  with  silkworm  or  catgul  sutures  before  continuing 
the  extirpation.  In  working  deep  in  the  lacrimal  fossa,  remember 
the  frailty  of  the  lacrimal  bone  composing  the  posterior  half  of 
that  depression. 

Third  step.^ — ^After  the  sac  is  loosened  from  all  attachments,  save 
the  common  and  nasal  ducts,   proceed  to  divide  those  with  the 


Fig.  68. — Extirpation  (jf  lacrimal 


lX'e[)  fasiia  ojJiMUMi  showing'  s;i 


scissors.  First  the  former.  Here,  if  much  traction  is  made  upon 
the  sac  while  in  the  act,  the  puncta  are  apt  to  be  inverted  or  drawn 
inward,  and  in  cutting  off  the  canaliculi  one  risks  making  button- 
holes of  the  lids  and  skin  about  them.  Having  freed  the  upper 
portion,  it  is  grasped  with  broad  fixation  forceps  and  held  up  while 
the  scissors  are  passed  down  into  the  nasal  opening  to  divide  the 
lower  end  or,  as  preferred  by  the  writer,  to  loosen  and  remove  it 
as  far  as  the  nasal  cavity.  Profuse  hemorrhage  is  rather  to  be  ex- 
pected, though  the  above-described  manner  of  making  the  incision, 


148     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

together  with  firm  pressure  of  its  inner  lip  against  the  bones  of  the  nose, 
the  use  of  a  broad  Desmarres  retractor  beneath  the  inner  lip  of  the 
incision  to  compress  the  vessels  against  the  nasal  bone  (Fig.  68), 
torsion  of  the  larger  spouting  vessels,  the  instillation  of  i-iooo 
solution  of  adrenalin  chlorid,  or  copious  douches  of  very  hot  water, 
or,  better  still,  hot  sublimate  solution  will  serve  to  keep  the  bleeding 
easily  within  bounds. 

IMuller  advises  the  hypodermic  injection  of  adrenalin  chlorid 
and  cocain  for  local  anesthesia  and  control  of  hemorrhage.  His 
technic  is  to  drop  one  minim  of  a  3  per  cent,  solution  of  cocain 
into  the  conjunctival  sac  three  times,  at  intervals  of  two  minutes, 
then  fdl  the  lacrimal  sac  with  a  i  per  cent,  solution  of  cocain.  With 
the  hypodermic  syringe  he  now  injects  a  solution  consisting  of  eight 
parts  of  I  per  cent,  cocain  and  two  parts  i — 1000  adrenalin  chlorid, 
just  above  the  inner  canthal  ligament,  just  below  the  inner  canthal 
ligament,  and  near  the  anterior  lacrimal  crest,  injecting  1-3  c.c.  at 
each  point.     The  operation  is  begun  immediately. 

Every  trace  of  the  sac  must  be  got  rid  of.  It  often  happens  that 
its  walls  are  so  tender  that,  in  spite  of  the  most  cautious  handling, 
they  are  torn.  I  have  found  that  in  such  instances  the  fingers  may 
with  advantage  be  substituted  for  the  forceps,  to  hold  it,  after  free- 
ing its  upper  end.  If  it  is  highly  degenerated  and  amorphous,  one 
cannot  always  hope  to  get  it  out  intact,  but  must  be  content  to  sponge 
out  the  cavity  as  dry  as  possible,  search  for  detached  islands  of  the 
walls  and  mucous  lining,  pick  them  up  with  the  forceps  and  excise 
them  with  the  scissors.  A  thickened,  tough  sac  can  easily  be  shelled 
out  entire.  Where  carious  bone  is  present  it  is  scraped  away  with 
a  hard,  sharp  curet,  no  matter  if  it  be  that  of  the  inner  w^all  of  the 
fossa  or  lacrimal  bone,  whereby  an  opening  is  made  into  the  nasal 
cavity.  Any  granular  masses  also  undergo  curettage,  and  this  sort 
of  cleaning  out  is  carried  down  into  the  nostril.  As  a  proper  finish, 
a  small  olive-tipped  electrode  is  used  to  cauterize  the  nasal  end  of 
the  canal.  This  last,  however,  miisi  not  be  done  so  long  as  the  in- 
flammable gases  from  the  anesthetic  are  near  about,  else  an  explosion 
will  ensue. 

Once  in  a  while  cutting  of  the  internal  canthal  ligament  is  an  in- 
evitable part  of  tlie  operation,  as  when  a  fistulous  opening  has  been 
established  above  it,  though  the  writer  prefers  leaving  it  intact 
whenever  possible.  The  incision  is  then  extended  up  through  the 
ligament.     After  the  lisliihi  lias  been  dealt  with — i.e.,  its  tract  has 


EXTIRPATION    OF    THE    SAC  1 49 

been  excised — and  before  closing  the  external  wound,  it  is  best  to 
unite  the  severed  fragments  of  the  ligament  by  a  catgut  suture.  As 
much  of  each  canaliculus  as  practicable,  without  buttonholing  at 
the  punctum,  is  removed,  and  if  there  are  any  misgivings  as  to  the 
capacity  of  what  remains  to  make  trouble,  they  may  be  obliterated 
by  searing  their  linings  with  a  delicate  galvano-cautery,  as  per 
Haab. 

The  opening  having  been  cleansed  and  the  bleeding  stopped,  it 
is  closed  by  three  or  four  pretty  deep  silk  sutures,  between  and 
beyond  which,  if  needed,  smaller  and  shallower  ones  may  be  in- 
serted. One  cannot  be  too  precise  in  approximating  the  lips  of  the 
incision.  Provided  the  extirpation  has  been  complete,  no  tent  nor 
drain  is  put  in.  This  is  done  only  when  there  is  some  doubt  as  to 
thoroughness. 

The  dressing  consists  of  the  usual  wet  sheet  of  cotton,  the 
thick,  dry  pad,  and  the  wet  netting,  monocular  bandage;  and 
sufhcient  pressure  must  be  kept  up  to  cause  obliteration  of  the 
cavity.  It  is  essential  that  a  ball  of  cotton  be  placed  immediately 
over  the  wound,  between  the  wet  layer  and  the  dry  pad,  to  insure 
such  obliteration.  The  sutures  are  removed  just  as  early  as  the 
condition  of  the  wound  will  allow.  If  this  be  in  forty-eight  hours, 
all  the  better.  Where  a  tent  is  required  as  a  drain  or  to  induce 
healing  by  granulation  from  the  bottom  of  the  opening,  a  strip  of 
iodoform  gauze  answers  the  purpose.  The  wound  is  closed  at 
either  extremity  and  the  gauze  is  left  projecting  from  the  middle. 
The  bandage  is  changed  daily — so  is  the  tent  if  used — until  per- 
manent closure  is  effected. 

Mr.  T.  Harrison  Butler,  Coventry,  before  the  British  Medical 
Association  at^^ Birmingham,  July,  191 1,  read  a  paper  describing 
a  new  operation  for  the  extirpation  of  the  lacrimal  sac.  He  said 
it  was  essentially  a  modification  of  Muller's  operation.  The  site 
of  the  sac  was  rendered  anesthetic  and  anemic  by  the  injection 
of  codrenine.  The  primary  incision  was  through  the  skin  only. 
It  took  the  form  of  a  half  circle  with  the  centre  at  the  canthus. 
The  flap  was  carefully  dissected  up,  avoiding  button-holing  or 
wounding  of  the  veins  underlying  the  nasal  side  of  the  incision. 
The  palpebral  ligament  was  then  isolated,  and  the  deep  fascia  split 
vertically,  so  as  to  expose  the  sac.  The  sac  was  freed  from  its  bed 
with  blunt-pointed  scissors,  and  pushed  down  under  the  ligament. 
Then  the  canaliculi  were  severed,  and  the  sac  drawn  down  toward 


I50 


OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 


the  duct,  twisted  to  a  cord,  and  cut  off.  The  operation  was  blood- 
less and  painless,  and  no  retractors  were  required,  only  sutures  to 
hold  back  the  flap  and  secure  the  ligament.  He  had  done  the  opera- 
lion  70  or  80  times,  and  was  more  than  pleased  with  the  results. 

Mellcr  gives  an  excellent  description  in  his  well-known  text- 
book of  extirpation  of  the  sac  as  performed  in  Menna. 

Toti's  Operation,  or  Dacryocysto-rhinostomy.  La  Clinica 
Modcrna,  Florence,  1904,  No.  35,  and  La  Clinica  OcuUsta,  April- 
May,  19 10)  .—Since  the  days  of  Celsus  and  Paul  of  Eginus  sur- 
geons have  striven  to  divert  the  drainage  of  the  lacrimal  secretions 


Fig.  69. — Toti's  operation.     The  heavy  curved  line  represents  the  incision 
of  the  soft  parts. 


from  the  nasal  duct  through  an  artificial  bony  opening,  directly 
from  the  tear  sac  into  the  nasal  cavity,  or  even  into  the  maxillary 
sinus.  But  the  opening  would  never  remain  patent  till  Toti  tried 
making  it.  It  seems  to  have  been  reserved  for  him  to  devise  a 
measure  by  which  the  object  sought  is  often,  at  least,  attained. 

TotVs  method  of  procedure  may  be  thus  described:  In  most  in- 
stances local  anesthesia  is  used,  that  is,  a  few  cubic  centimeters  of 
2  per  cent,  novocain  solution  with  three  or  four  drops  of  adrenalin, 
1-1,000,  are  injected  deep  into  the  parts  affected  by  the  incision,  and 
20  per  cent,  cocain  solution  is  applied  to  the  middle  meatus.  The 
others  who  have  ])erformed  the  operation  are  divided  between 
the  use  of   local  anesthesia  and  narcosis.      \Vhate\er  inler\cntion  is 


lOTI  S    Ol'KRATIOX  151 

demanded  by  the  adjacent  nasal  ra\ily  should  prcc  cde  the  lacrimal 
operation. 

An  incision,  deserihin,^  almost  a  semieirele.  is  made  surrounding 
and  concentric  with  the  internal  commissure  of  the  lids  (Fig.  69). 
It  should  be  at  least  3  cm.  in  len,«i;th,  and,  in  the  main,  runs  7jarallcl 
with  the  orbital  rim.  At  its  middle  it  lies  about  3  mm.  to  the  inner 
side  of  the  insertion  of  the  tcndo  ociili.  It  is  kept  perpendicular  to 
the  bone,  and  includes  all  the  soft  parts  down  to  the  periosteum. 
This  last  is  then  incised  from  the  brink  of  the  orbital  rim,  just  ex- 
ternal to  the  anterior  lacrimal  crest,  curving  in  the  same  way  around 
the  canthal  ligament,  thence  upward  and  backward  and  outward  to 


Fig.  70. — Toll's  operation,  i.  Inserlion  of  lendo  oculi.  4.  Anterior  lacrimal  crest. 
?.  Posterior  lacrimal  crest.  3.  Entrance  to  nasal  duct.  6.  Lacrimal  bone,  or  os 
unguis.  7.  Part  of  lacrimal  fossa  belonging  to  lacrimal  bone.  8.  Fart  of  fossa  belong- 
ing to  superior  maxilla.  2.  Line  of  periosteal  incision  and  limit  of  bone  resection 
continued  by  dotted  line. 


again  reach  the  brink  of  the  orbital  rim,  along  which  it  runs  till 
this. ridge  disappears  at  the  orbital  process  of  the  frontal  bone 
(Fig.  70).  The  posterior  (or  external)  lip  of  this  incision,  together 
with  all  that  is  attached  to  it,  is  raised,  the  loosening  extending  to 
the  entire  lacrimal  fossa.  The  bone  resection  is  begun  along  the 
undetached  lip  of  the  ])eriosteal  incision.     It  is  not  necessary  that 


152     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

it  should  extend  as  far  back  as  the  posterior  extremity  of  the  cut 
in  the  periosteum,  1)ut  it  is  imi)ortant  that  it  include  all  that  portion 
of  the  superior  maxilla  comprising  the  anterior  lacrimal  crest,  the 
infero-nasal  rim  of  the  orbit,  and  the  anterior  half  of  the  lacrimal 
fossa,  which  is  composed  of  the  rising  process  of  the  superior  maxilla. 
To  remove  the  portion  of  this  fossa  that  is  formed  by  the  lacrimal 
bone  will  often  lead  into  an  ethmoid  cell.  If  one  of  these  cells  is 
uncovered  it  may  be  resected.  The  bone  resection  is  carried  down 
posteriorly  to  the  junction  of  the  posterior  lacrimal  crest  and  the 
rim  of  the  nasal  duct;  and  anteriorly  as  well  into  this  duct  as  prac- 
ticable, care  being  taken,  all  the  while,  not  to  break  through  into 
the  nose  and  wound  its  mucous  lining.  After  drying  the  cavity,  the 
mesial  half  of  the  wall  of  the  lacrimal  sac  is  resected,  and  a  corre- 
sponding section  of  the  nasal  mucous  membrane,  likewise.  To 
facilitate  the  last  a  probe,  or  carrier,  with  a  ball  of  cotton  wound 
on  it,  is  passed  into  the  middle  meatus,  the  membrane  pushed  out 
into  the  bone  opening,  when  it  is  excised  with  the  point  of  a  knife. 
Before  proceeding  further  an  antiseptic  tampon  is  packed  in  the 
meatus  in  such  a  way  as  to  hold  the  edges  of  the  mucous  opening 
in  close  contact  with  those  of  the  bony  one.  The  wound  is  then 
closed  with  interrupted  sutures,  and  the  usual  dressing  applied, 
taking  the  precaution  to  so  build  the  pad  of  cotton  that  extra  pressure 
will  be  exerted  immediately  over  the  site  of  the  new  opening. 

Since  the  sole  aim  and  end  of  the  operation  is  the  relief  of  trouble- 
some epiphora,  unless  the  function  of  the  lacrimal  canal,  from  the 
conjunctiva  to  and  into  the  sac  is  undisturbed,  the  measure  will 
avail  nothing.  If  one  of  the  canaliculi  has  been  slit,  for  example, 
or  there  exists  a  stricture  at  the  union  of  canal  and  sac,  or  if  there 
is  eversion  of  the  lower  punctum,  the  operation  is  contra-indicated. 
Another  bar  to  the  procedure  is  chronic  and  progressive  disease 
of  the  adjoining  nasal  cavity.  When  done  in  cases  of  suppuration 
of  the  canal  it  does  not  remove  the  danger  of  infection  of  the  cornea 
that  may  arise  from  this  source.  As  to  the  relief  of  epiphora,  this 
occurs,  according  to  Fuchs,  in  probably  50  per  cent,  of  the  cases. 
Taken  all  in  all,  then,  the  procedure  is  somewhat  complicated. 

Obliteration  of  the  Sac— This  measure  is  indicated  when, 
through  long-standing  suppurati\e  disease,  with  numerous  exacer- 
bations, much  scar  tissue  with  extensive  adhesions,  thickening  of 
the  periosteum,  bone  lesions,  fistula,  and  fungosities  exist.  The 
incision  is  made  as  for  extirpation,  exce])t  that  it  includes  the  front 


EXTIRPATION   OF    THE    GLAND  1 53 

and  outer  wall  of  the  sac  and,  if  necessary,  the  internal  canthal 
ligament.  After  widely  separatinj;  the  Ups,  the  cut  in  the  front 
wall  is  extended  into  the  nasal  duct.  As  much  as  practicable  of  the 
sac  is  dissected  out,  the  rest,  together  with  the  fungosities  and  the 
carious  bone,  removed  by  scraping  with  a  strong,  sharp  curet,  and 
lastly,  the  entire  cavity  is  rather  deeply  seared  with  the  thermo- 
cautery. Iodoform  gauze  packing,  the  ordinary  pad,  and  bandage 
compose  the  dressing,  all  of  which  are  renewed  daily  under  antisep- 
tic irrigation,  until  the  wound  heals  from  the  bottom.  Later  it  may 
be  necessary  to  repeat  the  operation  one  or  more  times. 

Fistula  of  the  lacrimal  sac  will  sometimes  require  an  opera- 
tion for  its  cure,  when  the  indications  for  obliteration  or  extirpation 
of  the  canal  are  lacking.  A  tiny  fistula  that  pours  out  simply  tears 
will  usually  disappear  by  the  simple  operation  of  opening  up  the 
nasal  part  of  the  canal  by  probing,  preferably  without  slitting  up 
the  canaliculus,  with,  perhaps,  stimulation  of  the  tract  by  means 
of  the  galvano-cautery.  A  pus  fistula  may  yield  to  Bowman's 
operation,  the  use  of  the  syringe  and  the  Tansley  cannula  with 
potent  antiseptics.  Failing  in  this,  recourse  may  be  had  to  the 
more  radical  measure  of  incision  and  excision  of  the  tract  and 
closure  by  sutures. 

In  conclusion,  a  watchword  that  will  bear  repeating  is,  always 
the  conservation  of  the  lacrimal  canal  whenever  possible. 

Extirpation  of  the  lacrimal  gland,  taken  all  over,  is  an 
operation  frequently  performed,  yet  in  the  life  of  even  the  busiest 
ophthalmologist  in  general  it  is  resorted  to  very  rarely.  Truc^ 
classifies  the  surgical  measures  here  considered,  epigrammatically, 
as  follows: 

The  extirpation  of  the  whole  gland  is  an  operation  of  reserve 
(extremity) . 

The  extirpation  of  the  palpebral  gland  is  an  operation  Je  choix 
(option) . 

The  extirpation  of  the  orbital  gland  is  an  operation  de  necessite. 

The  indications,  are  neoplasms,  chronic  inflammations,  de- 
generations, and  persistent,  external  fistula  of  the  gland,  also  annoy- 
ing "epiphora  remaining  after  the  permanent  obliteration  of  the 
lacrimal  canal. 

Like  extirpation  of  the  sac,  that  of  the  gland  is  not  a  measure  to 
be^^adopted   lightly.     Diseases   and  some   benign   tumors  of   this 

'  Arch,  d'opht.,  T.  xiii,  p.  280,  1S93. 


154     OPERATIONS  UPON  THE  APPENDAGES  OF  THE  EYE 

organ  (as  those  from  syphilis)  are  often  amenable  to  other  means  of 
treatment.  An  external,  or  cutaneous,  fistula,  if  it  cannot  be 
healed  in  the  usual  way,  may  sometimes  be  converted  into  an  in- 
ternal or  conjunctival  one,  when  the  former  tract  either  disappears 
spontaneosluy  or  is  easily  dealt  with  by  excision.  Lastly,  an 
epiphora  that  has  been  profuse  before,  and  for  a  short  time  after 
extirpation  of  the  lacrimal  sac,  will  often  cease  altogether  or  become 
so  scant  as  lo  cause  no  inconvenience.  With  the  passing  of  the 
irritation  from  the  affected  drainage  division  of  the  apparatus, 
the  overactivity  of  the  secretive  part  subsides. 

Before  proceeding  to  describe  the  surgery  of  the  parts,  permit 
a  word  as  to  their  anatomy.  The  lacrimal  gland  is  a  double  organ, 
consisting  of  a  larger  superior  portion,  the  orbital  gland,  and  a 
smaller  inferior  portion,  the  palpebral  gland,  or,  as  it  has  also  been 
called,  the  accessory  lacrimal  gland   and   gland  of   Rosenmiiller. 

The  former,  surrounded  by  a  fibrous  capsule,  occupies  a  depres- 
sion in  the  bone,  under  the  supero-temporal  roof,  or  angle  of  the 
orbit.  Situated  above  and  to  the  outer  side  of  the  levator  palpe- 
bral superioris  tendon,  its  inner  border  almost  touches  the  outer 
fibres  of  the  superior  rectus,  and  its  outer  comes  near  the  upper 
fibres  of  the  externus.  In  size  and  shape  it  is  very  like  an  average 
lima  bean.  It  is  an  acinose  gland,  and  when  stripped  of  its 
capsule,  it  appears  as  a  grayish,  red  mass  of  closely  packed  lobules. 

The  lower,  or  palpebral  gland,  only  about  one-half  the  size  of 
the  upper,  is  composed  of  rather  scattering  lobules,  lying  just 
external  to  the  outer  third  of  the  upper  conjuctival  fornix.  The 
lowest  lobule  is  usually  found  in  the  immediate  vicinity  of  the  outer 
canthus.  It  may  be  above,  level  with,  or  even  below  it.  The 
uoter  fibres  of  the  levator  tendon  pass  between  the  orbital  and 
palpebral  lacrimal  glands.  Each  gland  has  separate  and  common 
ducts  all  emptying  into  the  outer  half  of  the  fornix  conjunctiva 
about  four  millimeters  above  the  convex  border  of  the  tarsus. 

Removal  of  the  whole  gland  has  been  accomplished  through  the 
fornix  or  transition  part  of  the  conjunctiva.  It  is  done  by  first 
making  a  free  canthotomy,  everting  and  stretching  upward  the  lid, 
till  the  superior  border  of  the  tarsus  (now,  of  course,  the  inferior) 
is  about  opposite  the  bony  rim  of  the  orbit,  then  making  an  incision 
just  below  and  parallel  with  the  tarsus,  from  the  junction  of  its 
middle  and  outer  third  and  extending  beyond  its  temporal  extremity. 
The  same  incision  enables  one  to  !j;cl  al  and  sliell  oul  l)()lh  glands. 


EXTIRPATIOX    OF    GLAND  1 55 

but  the  operation  is  a  (lirficull  one.  The  conjunctival  openin<<, 
therefore,  is  limited  in  its  use  mainly  to  the  removal  of  the  pal- 
pebral gland. 

Extirpation  of  the  Palpebral  Gland. — Cocain  anesthesia 
suffices.  When  the  lid  is  drawn  up,  as  above  described,  and  the 
patient  is  made  to  look  far  downward,  as  he  should  throughout  the 
operation,  the  imprint  of  the  lobules  can  be  seen.  Should  the 
patient  be  unruly,  or  should  the  eye  roll  involuntarily  up,  an  as- 
sistant grasps,  with  strong  forceps,  the  tendon  of  the  superior  rectus, 
as  per  Angelucci,  a  trick  that  works  like  a  charm  to  steady  both 
patient  and  globe,  as  well  as  to  hold  the  latter  down.  A  little 
adrenalin  solution,  painted  on  to  the  sj)ol  will  cause  immediate 
blanching,  when  the  incision  can  be  made  and  the  gland  exposed 
with  but  slight  bleeding.  As  advised  by  Panas,  a  strong  probe 
may  be  passed  down  behind  the  everted  upper  lid  to  bring  the 
gland  into  better  reach  of  hand  and  sight. 

The  incision  is  best  made  with  a  small  scalpel  having  a  highly 
convex  edge.  The  wound  is  held  open  with  the  smallest-sized 
retractors  or  the  tiny  strabismus  hooks  of  Stevens,  and  the  gland 
is  loosened  first  above,  then  below,  by  blunt  dissection  or  cutting 
with  stub-pointed  scissors.  When  the  lobes  are  in  view  and  fairly 
freed  from  surroundings,  they  are  drawn  out  and  severed  from 
their  posterior  attachments  by  cutting  w^ith  the  scissors,  from  the 
nasal  side  and  ending  at  the  temporal.  At  this  end  there  is  apt  to 
be  some  hemorrhage,  but  it  is  easily  controlled  by  styptics,  clamping, 
or  torsion. 

Extirpation  of  the  Palpebral  Portion,  together  with  the  de- 
generative effect  entailed  upon  the  ducts  of  the  orbital  gland,  will 
occasionally  sufhce  for  the  relief  of  epiphora.  It  is  well  known  that 
atrophy  of  the  conjunctival  sac,  following  trachoma,  results  in  the 
drying  up  of  the  source  of  the  tears,  hence  the  actual  cautery  has 
been  applied  (Chibret  and  Bettermieux)  to  the  retrotarsal  folds 
and  the  mouths  of  the  ducts,  with  a  view  to  the  discouragement 
of  further  lacrimal  secretion  or  the  induction  of  atrophy  of  the 
gland.  One  ought  to  avoid  unnecessary  opening  of  the  orbital 
fascia,  fearing  cellulitis,  and  know  how  to  distinguish  the  glandular 
tissue  from  that  of  the  orbital  fat.  The  first-named  is  pink  and  of 
firmer  consistency,  the  second,  yellow  and  softer.  A  couple  of  fine, 
absorbable  sutures  are  put  in  to  tolerably  close  the  conjunctival 
incision,  or  thev  mav  be  omitted,  and  tlie  coniunctiva  and  skin  of 


156  OPERATIONS    UPON    THE    APPENDAGES    OF    THE    EYE 

the  canthus  are  sutured  together  as  per  description — see  "  Cantho- 
plasty."  Canthotomy  is  often  dispensed  with  in  extirpation  of 
the  palpebral  lacrimal  gland.  The  levator  tendon  is  to  be  scrupu- 
lously shunned,  because  of  possible  ptosis.  A  safer,  easier,  and 
generally  preferable  method  for  the  extirpation  of  the  larger  gland 
is  by  way  of  the  external  incision. 

The  Operation  for  Extirpation  of  the  Orbital  Lacrimal 
Gland. — The  supercilia  are  lathered  and  smoothly  shaved  with  a 
razor.  For  the  most  part,  general  anesthesia  is  demanded.  The 
exact  mid-line  of  the  stumps  of  the  outer  half  of  supercilia  is  chosen 
for  the  site  of  the  cutaneous  incision,  so  that  most  of  the  scar  will 
be  hidden.  The  convex  scalpel  is  held  in  the  right  hand  while  the 
indicated  line  of  the  eyebrow  is  stretched  over  the  rim  of  the  orbit 
by  manipulation  of  the  left  thumb  and  index.  After  cutting 
the  skin  from  midway  of  the  eyebrow  to  its  outer  extremity,  the 
cut  is  continued  just  over  the  outer  rim  of  the  orbit  to  a  point  about 
on  a  level  with  the  outer  canthus.  It  is  then  deepened  until  the 
periosteum  is  reached,  then  pulled  downward  and  held  open  by 
some  form  of  retractor.  A  quite  fitting  instrument  for  the  purpose 
is  the  lid  speculum  of  Landolt  (Plate  VHI).  The  tarso-orbital 
fascia,  or  septum  orhitale,  is  next  incised  opposite  the  front  border  of 
the  gland,  and  from  three  to  four  millimeters  beneath  the  edge  of 
the  orbital  rim,  taking  care  to  keep  the  inner  end  of  the  incision  as 
far  as  practicable  toward  the  temple,  in  order  to  keep  out  of  the 
way  of  the  levator  and  its  nerve.  The  gland  is  laid  bare,  loosened 
with  curved,  dull-pointed  scissors,  working  now  closed  and  held 
pen-fashion  for  blunt  dissection,  again  cutting  the  stronger  fasten- 
ings of  the  gland — first  below,  then  above — the  latter  being  all  the 
while  slowly  and  steadily  drawn  forward,  until  it  comes  away 
entire.  At  this  stage,  the  lacrimal  artery  is  tied,  hemostatic 
forceps  applied  to  other  bleeding  vessels,  and  every  means  resorted 
to  for  the  prevention  of  deep  hemorrhage.  (See  Gifford,  ^ "  Extirpation 
of  the  lacrimal  gland,  causing  atrophy  of  the  optic  nerve,  through 
hemorrhage  into  the  orbit.")  Great  care  must  be  exercised  to  pre- 
vent injury  to  any  of  the  external  eye  muscles  or  to  their  nerve  supply. 
The  cavity  is  washed  out  with  sublimate  solution  and  the  opening 
in  the  tarso-orbital  fascia  is  closed  with  fine  gut  sutures.  The  lips 
of  the  outer  wound  arc  put  into  the  nicest  possible  apposition  and 
held  together  by  a  few  carefully  placed,  interrupted  sutures  of  paraf- 

'  Am.  J(jur.  of  Ophlluilmology,  Vol.  vi,  p.  268. 


REMOVAL    OF    ORBITAL    GLAND  1 57 

fined  silk.  The  usual  monocular  bandage  is  applied,  excepting 
that  the  pad  of  dry  cotton  is  larger  and  extends  up  higher  on  the 
forehead.  The  patient  is  put  to  bed  and  kept  quiet  and  the  eye 
regularly  inspected.  The  silk  thread  is  removed  as  soon  as  the 
healing  of  the  wound  will  permit.  If  signs  of  infection  appear,  the 
incision  must  be  at  once  reopened,  at  least  that  portion  of  it  involved 
by  the  threatening  process,  cleaned  out,  and  vigorously  treated  with 
strong  antiseptics. 


CHAPTER    IV. 

OPERATIONS    UPON    THE    EXTERNAL    MUSCLES    OF 
THE  EYE. 

Strabismus.— This  is  a  very  old  word,  of  Greek  origin,  whose 
more  modern  and  preferable  English  synonyms  are  squint  and 
hderotropia;  and  all  three  are  terms  that  refer  to  an  abnormal 
position  of  the  globe  whereby  its  visual  axis  fails  to  meet  that  of 
its  fellow  exactly  at  the  fixation  point.  Whatever  the  determining 
or  "exciting"  causes  of  squint— whether  errors  of  refraction,  ambly- 
opias, unawakened  fusion  centers,  etc. — it  is  certain  that  faulty 
muscles  are  in  most  cases  the  predisposing— the  real— cause. 
The  vast  majority  of  eyes  remain  free  from  strabismus,  no  matter 
what  the  state  of  the  vision,  the  refraction,  or  other  physical  conditions. 
Of  the  squinting  eyes,  approximately  only  about  one-third  are 
amenable  to  treatment  other  than  surgical.  It  is  of  the  utmost 
importance,  then,  that  one  should  study  well  each  separate  case, 
in  order  to  determine  the  nature,  the  degree,  and  the  contributing 
factors  as  regards  both  the  eyes  and  the  possessor  of  them;  and 
that  surgical  methods  should  not  be  resorted  to  saving  when  reason- 
able trial  of  all  other  appropriate  means  has  failed  to  remedy  the 
defect.     Then  only  is  an  operation  indicated. 

Kinds  of  Squint. — The  deviation  of  the  eye  is  spoken  of  as 
lateral,  or  horizontal,  when  it  turns  out  or  in;  as  vertical,  when  up 
or  down,  and  as  oblique  when  it  is  a  combination  of  the  two.  When 
the  eye  turns  inward,  the  squint  is  said  to  be  convergent  (esotropia) ; 
when  outward,  divergent  (exotropia) ;  when  upward,  sursunivergent 
(hypertropia),  and  when  downward,  deorsumvergent.  In  pure 
horizontal  deviation  inward  the  eyes  are  in  the  position  of  positive 
convergence,  because  the  lines  of  fixation  intersect  in  front  of  the 
eyes;  and  in  horizontal  deviation  outward,  they  are  in  that  of  negative 
convergence,  because  the  lines  of  fixation,  if  prolonged  backward, 
would  meet  behind  the  eyes.  At  a  matter  of  fact,  however,  in  most 
instances  the  squint  is  a  mixture  of  the  lateral  and  the  vertical 
varieties. 

All  squints  arc  divided  into  two  grand  classes,  depending  upon 
whether  the  eyes  arc  or  are  not,  under  certain  conditions,  able  to 


KINDS    or    SQUINT  I5Q 

assume  their  normal  relative  positions.  The  older  and  less  rational 
terms  to  denote  the  two  classes  were  non-paralytic  and  paralytic. 
Non-paralytic  strabismus  was  called  concomitant.  The  later  and 
better  terms  arc  comitant  and  incomitant.  The  lirst  includes  all 
those  in  which  the  direction  of  the  eyes  mij^hl,  throuii;!!  the  influence 
of  the  will,  the  effect  of  artificial  lenses,  the  action  of  drugs,  narcosis, 
etc.,  become  normal  in  any  part  of  the  held  of  hxation.  To  the 
second  belong  all  the  others,  whether  the  squint  be  due  to  paralysis, 
paresis,  from  any  cause,  or  to  congenital  shortness  of  a  muscle. 
A  further  classihcation  of  squint  is  into  constant  monolatcraU 
alternating,  and  intermittent.  In  the  first  class  the  deflection  is 
always  confined  to  the  same  eye;  in  the  second,  it  is  first  of  one 
eye  and  then  of  the  other.  In  the  third,  the  squint  is  absent  part 
of  the  time  and,  when  present,  may  be  either  monolateral  or  alter- 
nating.    By  far  the  most  common  form  of  squint  is  the  convergent. 

A  still  further  classification  is  into  primary  and  secondary  squint. 
The  former  comprises  all  save  those  unfortunate  cases  in  which 
deviation  of  an  opposite  kind  has  followed  the  too  free  severance  of 
a  muscle  from  the  globe  (overtenotomy)  or  the  prolonged  wearing 
of  the  full  correction  for  excessive  hypero]na. 

Then  there  is  that  state  of  the  ocular  muscles  in  which  there  is 
more  or  less  tendency  of  an  eye  to  wander,  and  actual  squint  is 
prevented  only  by  a  corresponding  degree  of  conscious  or  uncon- 
scious muscular  effort.  This  is  referred  to  as  latent  squint  or 
suppressed  squint.  It  is  also  the  dynamic  strabismus  of  Von  Graefe, 
and  the  heterophoria  of  Stevens. 

The  same  general  surgical  principles  are  applicable  to  all  forms 
of  squint— latent  or  manifest— yet  they  must  be  variously  modified 
to  answer  the  demands  of  individual  cases. 

With  rarest  exception  but  one  eye  squints,  while  the  other  fixes, 
and  the  two  are  designated  as  squinting  eye  and  fixing  or  working 
eye.  The  fact  that  the  squint  is  confined  to  one  eye  does  not  imply 
that  but  one  eye  is  concerned  in  the  defect.  As  first  ])ointed  out 
by  Bonders,  and  since  abundantly  verified,  strabismus  is  usually 
a  bilateral  affection.  Nor  does  it  follow  that  the  fixing  eye  is  pos- 
sessed of  a  better  muscular  system  than  the  squinting  one.  Often 
the  reverse  is  true.  Greater  visual  acuity,  a  lesser  refractive  error, 
etc.,  having  determined  it  to  do  the  work.  As  concerns  the  cases 
here  in  point,  viz.,  those  that  ultimately  require  surgical  measures, 
it  may  be  assumed,  for  all  practical  reasons,  that  the  defect  is  purely 


l6o        OPERATIONS  UPON  THE  EXTERNAL  MUSCLES 

a  muscular  one,  and  that  the  muscle  usually  concerned  is  that  one 
away  from  which  the  eye  turns,  or  its  fellow  of  the  other  eye;  or,  as  is 
most  often  the  case,  both  of  them.  That  is,  these  muscles  are  in- 
eflicient  or  abnormally  weak,  rather  than  that  their  opponents  are 
overactive  or  too  strong.  The  last  mentioned,  hov^^ever,  was  the 
original  idea,  and  upon  it  was  based  the  primitive  operation  of 
strabotomy.  To  this  day  the  Germans  call  the  muscle  toward 
which  the  eye  deviates  the  Shielmuskel — the  squint-muscle — and 
refer  to  the  one  truly  at  fault  as  merely  the  antagonist.  Every 
close  and  experienced  observer,  in  studying  the  conditions  of  the 
muscle  or  muscles  actually  involved  in  the  squint,  must  have  been 
aware  of  the  anomalies  so  often  present — anomalies  of  development, 
of  attachment  to  globe,  adhesion  to  the  fibrous  capsule,  etc. 

The  different  surgical  means  that  have  been  devised  for  the  cure 
of  squint  may  be  thus  denominated  and  arranged  according  to 
their  origin: 

f  a.  Myotomy. 

1.  Strabotomy  ^  ^_  tenotomy. 

2.  Tendon  advancement,  or  prorrhaphy. 

3.  Capsular  advancement. 

j  a.  Folding  or  tucking. 

4.  Tendon  shortenmg  ^  ^_  r,,,,^;^^, 

5.  Tendon  recession. 

6.  Operations  upon  the  check  ligaments. 

7.  Tendon  lengthening. 

These  various  measures  are  employed  either  singly  or  combined; 
as,  for  example,  a  muscular  with  a  capsular  advancement,  to  which 
may  be  added  a  tendon  resection,  or  a  tendon  folding,  and  so  on. 

I.  Strabotomy,  or  the  cutting  of  an  ocular  muscle,  for  the  cure 
of  strabismus,  like  the  entire  surgery  of  squint,  is  of  comparatively 
recent  date.  The  first  to  conceive  of  such  a  thing  was  the  gifted 
English  charlatan  oculist  "Chevaher"  John  Taylor,^  in  1738; 
though  he  did  not  carry  his  idea  into  effect,  contenting  himself 
merely  with  a  "fake"  operation,  viz.,  snipping  the  conjunctiva  of 
the  affected  eye,  then  closing  the  fixing  eye  by  means  of  adhesive 
plaster.  Of  course,  the  operated  eye  immediately  became 
"straight."     By  the  time  the  plaster  was  removed  the  operator  was 

'  De  Vera  causa  slrahismi,  Lisl)on,  1739. 


EARLY  TENOTOMIES  l6l 

paid  and  gone  to  other  iiclds.  We  have  some  muscle  snippers  in 
our  own  time  who  could  give  the  smooth  Chevalier  pointers. 

A  similar  suggestion  to  that  of  Taylor,  i.e.,  the  division  of  a 
muscle  to  correct  a  squint,  was  made  by  Eschenbach,  of  Rostock, 
in  1752.  Yet,  singular  to  relate,  for  a  hundred  years  from  the 
time  of  Taylor's  hint  no  attempt  was  made  to  put  the  notion  into 
actual  practice.  This  was  left  to  be  first  done,  ])ut  only  upon  the 
cadaver,  by  Stromeyer,  of  Hanover,  in  1838,  and  by  Dieffenbach, 
of  Berlin,  upon  the  living  subject  in  1839.  Dieffenbach's  early 
operation  was  essentially  a  myotomy  which  concerned  the  muscle 
toward  which  the  eye  deviated,  and  as  such  was  both  defective  and 
formidable.  It  consisted  in  a  free  opening  of  conjunctiva  and 
Tenon's  capsule,  drawing  forward  the  Shielmuskel — the  supposed 
faulty  muscle — and  the  complete  severance  of  its  body.  Naturally, 
in  an  era  when  asepsis  was  unknown  the  consequences  were  often 
dire.  Septic  orbital  cellulitis  and,  moreover,  secondary  squint, 
with  all  its  lamentable  attendant  defects,  were  so  common  that 
after  a  year  or  so  the  procedure  fell  into  dissuse.  About  this  time 
(1841)  Bonnet,  of  Lyons,  published  the  results  of  his  anatomical 
researches,  which  had  been  conducted  with  special  reference  to  the 
relations  of  the  ocular  muscles  and  the  various  ramifications  of  the 
fibrous  capsule  of  the  eye,  and  their  bearing  upon  the  surgery  of 
squint.  This  led  to  subconjunctival  myotomy,  which  lessened 
somewhat  the  dangers  of  infection,  and  later,  mainly  through  the 
efiforts  of  Jules  Guerin  (Nantes  and  Angers,  about  1845)  to  the  less 
harmful  and  simpler  operation  of  tenotomy,  and  still  later  (about 
1849)  ^^'^n  to  subconjunctival  tenotomy.  By  these  means  not  only 
was  infection  still  further  barred,  but  secondary  strabismus  be- 
came a  less  frequent  sequel.  The  operation  was  taken  up  with  a 
vim  by  A.  v.  Graefe  in  1853,  and  by  George  Critchett,  of  London, 
in  1857,  2.nd  improved  and  refined  till,  at  their  hands,  it  reached 
practically  the  status  in  which  it  is  found  to-day. 

Von  Graefe's  Method. — The  tendon  is  fully  exposed  by  either 
a  horizontal  incision  through  conjunctiva  and  capsule  of  Tenon, 
passing  over  the  insertion,  or,  as  was  most  often  preferred,  by  a 
vertical  incision  between  the  insertion  and  the  cornea.  The  con- 
junctiva is  undermined  toward  the  neighboring  canthus  with 
blunt  scissors,  the  Graefe  strabismus  hook  is  inserted  beneath  the 
tendon,  he  latter  lifted  somewhat  and  severed  from  the  sclera  with 
blunt  scissors  as  close  as  practicable  to  its  attachment.     The  hook  is 


l62  OPERATIONS    UPON   THE   EXTERNAL   MUSCLES 

reinserted  to  secarch  for  any  uncut  fibres  of  the  tendon,  which,  if 
found,  are  also  divided.  Lastly,  the  conjunctival  wound  is  closed 
by  a  fine  suture. 

Von  Arlt,  of  Vienna,  made  tenotomy  after  the  manner  of  v.  Graefe, 
save  that  he  picked  up  the  exposed  tendon  with  the  mouse- 
tooth  or  toothed  fixation  forceps,  instead  of  with  the  hook,  but 
used  the  hook  in  finding  and  severing  remaining  fibres.  This 
surgeon  was  most  circumspect  in  determining  the  position  and 
extent  of  his  incision  through  the  membranes,  choosing  a  small 
horizontal  one  over  the  center  of  the  tendon  for  the  lower  degrees  of 
strabismus  and  a  freer  vertical  one  over  the  insertion  for  the  higher 
grades.  If  it  was  feared  that  the  separation  of  the  muscle  from  the 
globe  was  extreme,  the  aponeurosis  of  the  tendon  was  included  by 
the  suture  which  finally  closed  the  vertical  wound;  if  not,  only  the 
conjunctiva  was  included. 

Critchett's  Subconjunctival  Tenotomy. — With  strong  mouse- 
tooth  forceps,  pressed  firmly  upon  the  globe  over  the  lower  border 
of  the  tendon,  just  behind  its  insertion,  a  horizontal  fold  of  con- 
junctiva and  underlying  capsule  of  Tenon  is  picked  up  and  cut 
crosswise  with  blunt-pointed  scissors  close  to  the  forceps,  if  possible 
dividing  both  membranes  at  one  snip,  though  it  may  be  necessary 
to  pick  up  the  capsule  in  a  similar  fold  and  incise  it  separately. 
Thus  a  vertical  wound  opening  is  made.  The  lower  border  of  the 
tendon  is  now  brought  to  view  by  gently  lifting  with  the  forceps  the 
fold  of  membrane  still  retained  in  its  jaws  and  touching  the  wound 
with  the  sharpened  point  of  a  cotton  sponge.  A  delicate,  flattened 
Graefe  hook  is  then  inserted,  point  up,  beneath  the  tendon,  pushing 
it  snug'up  to  include  all  the  fibres,  the  forceps  relinquished  by  the 
left  hand  for  the  hook,  which  is  slightly  raised.  One  point  of  the 
delicate  blunt-pointed  scissors  is  passed  beneath  the  tendon  close 
to  its  attachment  and  the  other  beneath  the  conjunctiva,  and  the 
tenotomy  accomplished  by  successive  snips  of  the  scissors,  cutting 
from  the  heel  to  the  point  of  the  hook.  As  in  the  Graefe  method, 
stray  fibres  that  have  escaped  the  scissors  are  sought  and  divided. 
If  still  greater  effect  is  desired  a  subconjunctival  incision  is  made 
vertically  in  Tenon's  capsule,  a  little  back  of  the  point  where  the 
tendon  was  cut.  Unless  there  is  a  tendency  of  the  conjunctival 
wound  to  gape,  no  suture  is  employed. 

Snellen's^  Subconjunctival  Tenotomy. — The  Utrecht  master 

'  Klin.  Monatshl.  f.  Augcnli.,  1S70,  S.  26. 


TENOTOMY  163 

has  given  an  invaluable  procedure.  The  conjunctiva  and  capsule 
are  picked  up  by  strong  mouse-tooth  forcejjs  in  one  horizontal 
fold,  as  in  the  Critchett  operation,  not  over  the  border  of  the  tendon 
but  over  its  center,  and,  if  possible,  the  tendon  itself  is  contained 
in  the  bite,  which  is  made  a  little  back  of  the  insertion.  The  entire 
fold  is  lifted  and  cut  athwart  by  the  blunt  scissors  close  to  the 
forceps,  on  the  corneal  side,  and  the  wound  peered  into  to  see  whether 
or  not  the  tendon  has  been  nipped.  If  not,  its  center  is  caught  up 
in  a  longitudinal  pleat  in  which  a  tiny,  perpendicular  buttonhole  is 
cut.  Still  holding  up  the  fold,  a  small  hook  is  introduced,  point  up- 
ward, at  this  hole,  and  the  upper  half  of  the  tendon  severed  by 
cutting  with  the  blunt  scissors  from  heel  to  point  of  the  hook 
beneath  the  membranes  and  between  the  hook  and  the  insertion. 
Still  holding  with  the  forceps,  the  hook  is  placed,  point  downward,' 
under  the  lower  half  of  the  tendon,  and  that,  in  like  manner,  is 
divided.  After  the  example  of  v.  Arlt,  if  greater  effect  is  desired 
the  incision  in  Tenon's  capsule  is  extended,  subconjunclivally, 
both  above  and  below.  The  conjunctival  wound  may,  according 
to  the  judgment  of  the  operator,  be  closed  by  a  thread,  or  its  edges 
simply  cleansed  and  approximated  by  means  of  the  forceps.  Snel- 
len, in  beginning  his  operation,  sometimes  grasps  the  tissues  in  the 
opposite  sense,  i.e.,  over  the  center  of  the  tendon,  but  into  a  verti- 
cal fold. 

George  T.  Stevens,  of  New  York,  has  somewhat  modified  Snel- 
len's method  into  a  partial  tenotomy  and  has  devised  a  set  of  deli- 
cate strabismus  instruments  (Plates  II  and  III).  Whatever  may  be 
said  concerning  the  modification,  it  is  certain  that  the  implements 
leave  little  to  be  desired  along  this  line.  The  present  writer  adopted 
the  Snellen  operation  and  the  Stevens  instruments  more  than  fifteen 
years  ago,  and  has  since  employed  them  in  preference  to  others. 
The  following  constitutes  the 

Author's  Mode  of  Making  the  Snellen  Tenotomy. — Assuming 
that  we  have  to  do  with  a  case  of  convergent  squint  of  the  right  eye, 
the  eye  is  prepared  and  anesthesia — local  or  general — is  produced. 
Local  anesthesia  is  preferable.  The  patient  lies  on  a  table,  at  the 
head  of  which  the  surgeon  stands.  The  blepharostat  is  put  in  place 
and  the  conjunctival  sac  thoroughly  irrigated  with  warm  boric 
solution,  the  remains  of  which  are  sponged  away.  If  the  eye  is  under 
local  anesthesia,  as  is  the  rule,  the  patient  is  instructed  to  look  all 
the  while  to  the  extreme  right.     The  outlines  of  the  tendon  and  in- 


164        OPERATIONS  UPON  THE  EXTERNAL  MUSCLES 

sertion  of  the  internus  can  now  be  indistinctly  perceived.  If  they 
are  about  in  their  normal  positions,  the  mouse-tooth  forceps  is 
placed  in  contact  with  the  globe,  with  jaws  separated  some  six  or 
eight  millimeters,  and  just  below  the  center  of  the  tendon  in  such  a 
way  as,  when  bearing  firmly  down  and  closing  the  forceps,  to  form 
aVertical  fold  three  or  four  millimeters  in  height,  composed  of  con- 
junctiva, capsule,  and  tendon.  Holding  the  forceps  tightly,  the 
fold  is  slightly  lifted,  and  with  the  Stevens  scissors,  with  their  con- 
cavity directed  toward  the  operator,  one  essays  by  a  single  sturdy 
snip  to  cut  through  all  three  layers  of  the  fold  close  to  the  forceps, 
thus  making  in  each  a  small  horizontal  incision. 

The  forceps,  still  holding  fast,  is  slightly  tilted  away  from  the 
operator  to  cause  the  wound  to  gape.  If  the  attempt  has  succeeded, 
"the  bare  shining  sclera  is  seen  at  the  bottom  of  the  wound.  If 
necessary,  the  tip  of  a  cotton  sponge  is  applied  to  the  opening  to 
clear  away  the  blood.  The  scissors  are  now  exchanged  for  the 
Stevens  hook,  which  is  inserted,  point  downward,  beneath  the  lower 
half  of  the  tendon,  close  up  to  its  insertion.  The  fold  held  till 
now  by  the  forceps  is  let  go,  the  membranes  below  the  cut  are  seized 
with  the  forceps  and  pushed  downward  so  as  to  expose  the  point  of 
the  hook,  behind  which,  by  tilting  it,  they  are  caught.  Now, 
making  traction  outward  and  upward  with  the  hook,  held  in  the 
left  hand,  the  lower  half  of  the  tendon  is  severed  from  the  globe 
close  to  its  attachment,  cutting  carefully  with  the  scissors  from  the 
heel  toward  the  point  of  the  hook.  Those  who  make  complete 
tenotomies  will  here,  of  course,  divide  the  entire  half  of  the  tendon. 
It  is  the  writer's  invariable  practice,  however,  except  in  the  opera- 
tion of  tendon  recession,  to  leave  both  borders  of  the  tendon,  or  at 
least  its  lateral  fibrous  expansions,  intact.  The  section  is,  therefore, 
stopped  a  millimeter  or  so  short  of  the  lower  edge  of  the  tendon. 
The  hook  is  held  beneath  the  uncut  border,  the  scissors  are  exchanged 
for  the  other  hook,  whicli,  in  turn,  is  placed  beneath  the  upper 
half  of  the  tendon,  the  I'lrst  hook  is  removed,  the  membranes  pushed 
beyond  its  point  with  the  forceps,  and,  again  taking  the  scissors, 
the  upper  section  of  the  tendon  is  made  precisely  as  had  been  the 
lower — that  is,  sparing  the  border.  The  result  of  the  ])rocedure  is 
a  small  horizontal  incision  in  both  membranes  and  a  vertical  button- 
hole in  the  tendon,  which  separates  all  of  its  more  central  fibres 
from  their  former  atlachment.  The  eye  is  again  douched  with  the 
warm  boric  solution,  as  it  has  l)een  sexcral  times  during  the  opera- 


ACCIDENTS    IN    TENOTOMY  1 65 

tions  with  the  double  purpose  of  cleanhness  and  to  prevent  dryness 
of  the  corneal  epithelium,  and  the  membranes  are  carefully  re- 
arranged.    No  suture  is  put  in. 

I  make  this  operation  only  as  the  first  step  in  muscular  advance- 
ment, never  as  a  single  surgical  measure.  The  advancement  ])ro[)cr, 
as  described  further  on,  is  then  proceeded  with. 

Accidents  and  Complications,  Immediate  and  Consecutive.— 
While  the  operation  of  tenotomy,  as  performed  to-day,  is  one  of  the 
safest  of  surgical  procedures  as  regards  any  serious  instant  mishap 
or  any  grave  sequel  that  threatens  actual  loss  of  the  eye,  yet  these  very 
things  have  happened,  to  experienced  surgeons  as  well  as  to  the 
tyro,  in  this  branch  of  his  art.  Not  only  are  these  greater  dangers 
to  be  avoided  by  every  possible  means,  but  there  are  a  number  of 
lesser  untoward  Iiappenings  to  be  guarded  against.  Among  the 
immediate  arc: 

Hemorrhage  from  the  conjunctiva  and  Tenon's  capsule.  The 
larger  vessels  of  these  membranes  are,  as  a  rule,  ])lainly  visible  and 
can  be  avoided  by  cutting  to  one  side  of  them.  This  is  j^articularly 
true  of  the  capsule,  where  a  large  vein  is  seen  to  extend  longitudi- 
nally over  the  centre  of  tendon  and  muscle,  and  it  is  through  wound- 
ing of  this  that  the  worst  hemorrhages  come.  The  most  to  be  dreaded 
from  the  bleeding  is  a  large  hematoma,  which  is  in  the  way,  and 
tends  to  complicate  the  healing  process.  Because  of  their  secondary 
relaxing  effect  upon  the  walls  of  the  blood-vessels,  I  am  very  sparing 
in  the  use  of  such  things  as  cocain  and  adrenalin.  Indeed,  I  have 
practically  abandoned  the  last,  and  as  to  cocain,  limit  both  strength 
and  quantity  to  the  minimum  that  will  produce  anesthesia,  and 
attempt  to  make  the  operation  under  the  primary  effect:  one  minim 
of  a  2%  to  4%  solution  dropped  onto  the  site  of  the  tenotomy  twice, 
or,  at  most,  three  times,  with  two-minute  intervals;  then  a  wait  of  five 
minutes  after  the  last  drop  before  beginning  the  operation,  is  the  rule. 
Subconjunctival  injections  of  these  solutions  I  never  resort  to, 
not  so  much  because  of  the  danger,  which  is  slight,  but  because  of 
the  inconvenience  occasioned  by  the  ensuing  infiltration.  Another 
source  of  hemorrhage  is  indiscriminate  cutting  about  with  the 
scissors  beneath  the  conjunctiva  and  Tenon's  capsule.  All  such 
dissection  is  absolutely  uncalled  for,  and  pernicious,  save  in  cases 
where  one  encounters  cicatricial  tissue,  as  from  a  former  operation. 
It  were  also  easy,  by  thus  snipping,  to  wound  the  deeper  layers 
of  the  orbital  fascia,  exposing  the  fat  and  risking  what  is  perhaps 


1 66  OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 

the  gravest  accident  that  ever  occurs  after  tenotomy  of  a  rectus, 
viz.,  septic  orbital  cellulitis. 

Perforation  of  the  sclera  in  severing  the  tendon  has  often 
occurred,  and  is  a  casuaUy  as  inexcusable  on  the  part  of  the  operator 
as  it  is  serious  for  the  operated,  yet  nothing  but  the  greatest  watchful- 
ness will  prevent  its  happening  to  even  the  most  skilled  and  expe- 
rienced surgeon.  To  avoid  it  one  should  never  use  pointed  scissors, 
never  pull  up  the  tendon  strongly  and  cut  obliquely  from  behind 
its  insertion  close  down  to  the  sclera,  and  never  cut  too  much 
under  cover  of  overlying  membranes.  Whenever  possible  the  bite 
of  the  scissors  should  be  squarely  at  a  right  angle  to  the  long  axis 
of  the  muscle. 

Tenotomy  of  the  wrong  muscle  or  upon  the  wrong  eye  is 
to  be  guarded  against.  To  tenotomize  the  corresponding  muscle 
of  the  eye  not  intended  w^ere  less  harmful  than  pardonable,  seeing 
that  squint  is  usually  the  result  of  a  binocular  defect.  Should  the 
opposite  muscle  of  either  eye  be  cut,  however,  it  should  be  at  once 
picked  up  and  reattached  to  the  globe  by  one  of  the  various  suture 
methods  employed  for  advancement,  though  the  cut  end  of  the 
muscle  should,  of  course,  be  drawn  up  only  far  enough  to  meet 
the  stump  from  which  it  had  been  severed. 

Of  the  consecutive  accidents,  by  far  the  most  common  come  mainly 
from  a  too  complete  section  of  the  tendon.     They  are: 

1.  Retraction  of  the  caruncle,  leaving  only  a  dark  hole  where 
this  little  body  should  be. 

2.  Lack  of  motility  of  the  globe  in  the  direction  of  the  operated 
muscle. 

3.  Exophthalmos,  with  its  attendant  widening  of  the  palpebral 
fissure,  or  pro  ptosis. 

4.  Secondary  squint,  or  the  ultimate  deviation  of  the  globe  in  the 
contrary  direction  to  that  for  which  the  tenotomy  was  made. 

Knowing  the  cause,  the  preventive  is  obvious  and  readily  avail- 
able; yet,  having  once  occurred,  the  remedy,  whilst  it  may  be  quite 
manifest,  is  not  so  easy  of  application.  To  my  mind  the  proper 
thing  to  do,  whether  secondary  strabismus  exists  or  not,  is  to  try  to 
restore  the  relation  of  the  muscle  to  the  globe,  even,  if  need  be,  at 
I  he  cost  of  re-establishing  the  original  squint  at  the  same  time. 
This  would  be  a  big  choice  of  the  two  evils  and  could  then  be  dealt 
with  more  intelligently  and  scienlifically.  To  widen  the  palpebral 
ilssure  of  the  other  eye  for  the  proptosis,  for  example,  as  has  been 


SEQUELS    OF    TENOTOMY  1 67 

recommended,  and  even  practised,  is  preposterous.  If,  on  the  other 
hand,  one  is  at  once  aware  of  having  gone  too  far  in  any  direction, 
he  ought,  then  and  there,  to  make  an  effort  to  set  matters  aright. 
If,  for  instance,  he  thinks  the  capsule  has  been  too  greatly  pushed 
back,  or  too  freely  opened,  or  knows  that  the  tendon  had  been  too 
extensively  divided,  or  that  the  extreme  lateral  fibres  have  been 
cut  on  one  or  both  sides,  a  small,  absorbable  suture  should  be  so 
put  in  as  to  correct  the  error.  Even  after  the  lapse  of  two  or  three 
days,  if  it  is  evident  that  a  blunder  has  been  made  along  this  line,  it 
is  not  too  late  to  try  to  rectify  the  consequences;  for,  while  union 
may  be  firm,  there  being  no  scar  tissue  as  yet,  the  parts  may  be  still 
separated  without  difficulty.  Aside  from  the  bad  results  of  a  com- 
plete tenotomy  may  be  mentioned  those  of  extensive  incisions  in  the 
conjunctiva  and  in  Tenon's  capsule.  This  is  especially  true  if 
they  are  made  in  the  vertical  sense.  This  alone  leads  to  retraction 
of  the  caruncle,  slow  healing,  extensive  adhesions,  granulomata, 
and  other  complications.  Whether  or  not  one  chooses  the 
better  direction  for  these  incisions,  i.e.,  the  horizontal,  he  should 
see  to  it  that  there  is  not  undue  gaping  of  the  cut  edges  of  the 
membranes. 

If  exuberant  granulations  spring  up,  or  a  polyp  occurs,  at  the  site 
of  the  tenotomy,  a  drop  of  cocain  solution  and  a  snip  of  the  scissors 
constitute  an  effectual  remedy. 

In  warding  off  other  sequels,  such  as  conjunctivitis,  tenonitis, 
etc.,  absolute  cleanliness  of  the  eye,  the  instruments — in  short  of 
everything  concerned — is  the  best  safeguard.  Add  to  this  perfect 
occlusion  of  the  eye  and  the  strictest  quietude  of  the  patient  after 
the  operation,  and  about  all  is  done  that  can  be.  Often  too  little 
attention  is  paid  to  the  dressing  of  the  eye  after  this  sort  of 
operation.  In  view  of  the  fact  that  so  many  of  the  subjects  are 
children,  one  should  be  all  the  more  exacting  in  these  respects. 
I  lind  that  the  use  of  the  wet  netting  bandage,  and  flexible  collodion 
to  fix  it,  makes  an  excellent  dressing  in  every  way.  (Described  in 
chapter  on  Dressings.)  Extensive  adhesions  and  scar  tissue  after 
tenotomy  are  to  be  avoided  chielly  because  by  their  action  in 
binding  the  tendon  and  tension  on  the  check  ligaments  they  restrict 
the  movements  of  the  globe.  They  are  usually  the  result  of  un- 
necessary traumatism  at  the  time  of  the  operation,  mostly  through 
futile  and  aimless  poking  and  gouging  with  hooks,  slashing  with 
scissors,  and  mangling  with  forceps. 


l68  OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 

There  is  no  advantage  in  a  subconjunctival  tenotomy  over  one 
that  is  made  with  the  tendon  in  plain  view;  much  to  the  contrary. 
In  the  first  place,  one's  work  is  more  uncertain,  being  out  of  sight, 
and  precision  is  the  key-note  to  success.  In  the  second,  it  has  been 
proven  that  there  is  less  apt  to  be  unfavorable  reaction  after  the 
open  method,  seeing  that  bacteria  and  blood  can  be  much  more 
thoroughly  got  rid  of. 

As  to  dosing  the  effect  of  a  tenotomy;  to  assert  that  so  much  cutting 
in  a  given  manner  means  so  many  degrees  of  permanent  rotation  of 
the  globe  away  from  the  muscle- attacked  has  always  seemed  to  the 
writer  to  be  the  acme  of  absurdity.  Granting  that  a  tendon  can 
be  set  back  a  specific  distance,  what  assurance  have  we  that  it  will 
remain  in  that  position?  It  is  pretty  certain  that  if  the  borders 
of  the  tendon  are  both  left  intact  and  if  the  tenotomy  has  been  ac- 
complished with  the  minimum  of  traumatism,  the  ultimate  result 
will  be  nil.  After  the  complete  tenotomy  it  would  seem  to  be  merely 
a  question  as  to  how  much,  or  how  little,  harm  is  done.  The 
result  is  purely  problematical.  If  the  tendon  has  not  been  too 
greatly  loosened  from  its  sheath,  it  may  creep  back  to  its  place  again 
or  it  may  recede  to  a  greater  or  a  lesser  distance,  depending  upon 
wherever  it  can  find  an  attachment  or  can  come  to  rest.  To  divide 
the  tendon  all  from  one  side  leaving  a  single  border  uncut  tends 
to  produce  torsion  of  the  globe. 

Probably  the  least  doubtful  way  of  obtaining  a  definite  degree  of 
effect  is  to  make  section  of  all  but  the  outermost  fibres  of  the  tendon, 
then  resort  to  one  of  the  several  guy-threads  such  as  have  been 
invented  by  Graefe,  Knapp,  Griining,  and  others.  These  consist 
mostly  in  passing  a  ligature  through  the  episcleral  or  scleral  tissue, 
close  to  the  cornea  on  the  opposite  side  to  that  whereon  the  tenotomy 
occurs,  whereby  the  globe  is  pulled  into  extreme  duction,  when  the 
ligature  is  coiled  upon  the  temple  or  nose  as  the  case  may  be,  and 
there  fastened  with  collodionized  cotton.  The  ligature  is  a  source 
of  both  pain  and  danger. 

Another  somewhat  less  positive  but  much  safer  method  is  to 
make  section  of  the  entire  tendon,  drop  it  back  the  desired  distance, 
and  fix  it  there  by  a  thread.  This  operation  will  be  described  later 
under  "Curb  Tenotomy." 

Were  I  asked  to  name  the  indications  for  tenotomy  of  a  rectus 
muscle,  I  should  say  buttonholing  the  center  of  the  tendon  at  the 
time   an   ad\anccm(.'nt   is   made   on    its   antagonist   to   ])rc\-cnt,   by 


TENDOX    ADVAXCEMF.XT 


169 


weakening  it,  the  cutting  out  of  the  thread  used  in  the  advancement, 
and  complete  tenotomy  only  in  case  of  a])normaI  sliortness  of  the 
muscle,  as  it  is  found  in  certain  cases,  as,  for  example,  congenital 
strabismus — -then  always  with  the  curb  suture  just  alluded  to. 
These  are,  in  my  opinion,  the  only  tit'o  indications. 

2.  Tendon  Advancement. — Dieffcnbach,  of  Berlin,  attempted 
advancement  of  the  retracted  muscle  for  the  secondary  scpiint  that 
occurred  after  one  of  his  myotomies  as  early  as  the  year  1842, 
but  the  results  were  not  gratifying.  Guerin,^  of  Nancy,  was  the 
first  to  make  practicable  such  a  procedure.  He,  too,  was  incited  to 
make  the  operation  by  a 
desire  to  relieve  secondary 
squint,  many  instances  of 
which  were  all  about — the 
ugly  fruits  of  the  (then) 
new  fad  of  muscle-cutting. 
Just  the  precise  technic 
these  surgeons  adopted  I 
have  not,  as  yet,  been  able 
to  ascertain.  One  of  the 
first  published  descriptions 
of  an  advancement  opera- 
tion   is    that    of    Albrecht 

von  Graefe.-  It  is  substantially  as  follows:  Supposing  we  have 
to  do  with  a  divergent  strabismus  of  the  right  eye  (Fig.  71).  The 
conjunctiva  and  Tenon's  capsule  are  incised  over  the  insertion  of 
the  internus,  and  its  tendon  completely  severed  from  the  globe. 
The  membranes  are  then  opened  over  the  insertion  of  the  externus, 
its  tendon  lifted  on  a  hook,  a  ligature  is  passed  through  the  middle 
of  the  tendon,  close  to  its  attachment,  from  the  scleral  side  outward. 
The  ligature,  wdiich  includes  about  1/2  the  width  of  the  tendon, 
is  tied  and  given  to  an  assistant.  While  traction  is  made  with  the 
ligature  toward  the  cornea,  the  operator  gently  pushes  the  hook 
toward  the  outer  canthus;  from  1/2  to  3/4  the  width  of  the  tendon 
is  divided  by  the  scissors,  some  2  mm.  behind  the  thread.  The 
degree  of  section  is  proportioned  according  to  the  resistance  the  mus- 
cle is  supposed  to  offer  against  rotation  to  the  other  side.  The  eye 
is  now  turned  into  extreme  adduction,  and  the  ligature  is  fastened 

'Ann.  d'oculist.,  vol.  xxii,   1849. 

2  Arch.  f.  Ophth.,  iii,  No.  i,  1857,  p.  342-344. 


Fig 


Gracfc's  "  fadcn  operation." 


OPERATIONS  UPON  THE  EXTERNAL  MUSCLES 


to  the  nose  by  diachylon  plaster  (or  other  adhesive),  care  being 
taken  to  so  place  the  thread  that  it  will  not  infringe  upon 
either  lid  border,  i.e.,  exactly  in  line  with  the  closed  palpebral 
fissure.  If  the  bridge  of  the  nose  is  not  sufficiently  high  to  hold  the 
ligature  clear  of  the  cornea,  it  is  built  up  by  means  of  the  diachy- 
lon plaster.  Such  is  von  Graefe's  famed  "Faden-operation" 
(thread  operation)  that  has  been  so  much  criticised  and  ridiculed. 
As  a  matter  of  fact,  it  is  not  by  any  means  one  of  the  poorest  of  the 
many  clever  devices  of  this  genius  in  ophthalmology.  It  embodies 
the  partial  tenotomy  of  the  stronger  muscle  and  the  (intended) 
advancement  of  the  weaker,  and  provides  an  ingenious  and  practical 
means  of  holding  the  globe  in  a  favorable  position  for  the  reattach- 
ment of  the  advanced  mucle.  True,  von  Graef  e  abandoned  it  because 
of  injury  to  the  cornea  sustained  by  certain  of  the  operated  through 
contact  of  the  ligature.  But  with  the  ligature  anchored  at  the  in- 
sertion, with  vertical  buttonholing  of  the  tendon,  careful  fastening 
of  the  ligature  on  the  nose  by  collodionized  cotton,  and  with  modern 
methods  as  to  antisepsis  and  dressings,  this  source  of  danger  would 
cease  to  be  a  factor;  yet  there  would  still  remain  the  discomfort  to 
the  patient,  for  the  pain  was  said  to  be  severe  during  the  several  days 
the  ligature  was  left  in.  Where  the  operation  chiefly  failed  was 
that  the  internus  (in  the  case  cited)  was  expected  to  advance  of  its 
own  accord  and  take  its  new  hold  upon  the  globe,  instead  of  re- 
tracting as  it  always  does.     Had  this  been  brought  forward  and 

sutured  before  the  guying,  the 
history  of  the  procedure  might  be 
a  very  different  one.  This  was  an 
attempted  advancement  without  a 
single  suture. 

About  this  same  time  George 
Critchett,!  of  London,  devised  his 
multiple  suture  operation,  which  is 
the  parent  of  most  modern  advance- 
ment methods  (Fig.  72).  It  may 
be  thus  briefly  described:  A 
vertical  incision  about  1/2  inch  long,  is  made  between  the  cornea 
and  the  insertion  of  the  tendon  to  be  advanced,  through  conjunctiva 
and  Tenon's  capsule.  This  is  opened  up,  the  tendon  is  laid  bare 
and  lifted  on  a  strabismus  hook,  seized  near  its  middle  with  clamp 

'  Med.  Times  and  Gazette,  Nov.,  1S57. 


Fig.  72. — Critchett's  advance- 
ment operation. 


LANDOLT  S    ADVAXCEilENT  I? I 

fixation  forceps,  and  severed  from  the  globe  flush  with  the  sclera. 
If  need  be,  a  small  strip  is  trimmed  off  the  cut  end  of  tendon. 
While  an  assistant  holds  the  forceps,  three  separate  sutures  are 
passed  downward,  through  the  tendon,  after  having  picked  up  a  bite 
in  the  overlying  membranes,  one  near  each  border  and  one  at  the 
middle.  The  first  two  threads  are  carried  forward,  beneath  the  con- 
junctiva, to  emerge  near  the  upper  and  lower  limbus,  respectively, 
close  to  the  vertical  meridian,  while  the  third  is  given  a  similar  hold 
exactly  in  the  horizontal  meridian,  coming  out  at  the  limbus.  The 
middle  suture  is  tied  first,  to  hold  the  muscle  in  its  proper  place, 
then  the  other  two.  When  occasion  demanded  it,  a  fourth  suture 
was  put  in.  This  operation,  very  slightly  changed,  is  still  the 
favorite  method  with  many  ophthalmic  surgeons.  At  the  hands  of 
the  majority,  the  fixation  forceps  has  given  way  to  some  form  of 
tendon  clamp,  and  the  anchorage  of  the  needles  is  deeper. 

Landolt,iof  Paris,  modified  Critchett's  operation  in  several  im- 
portant respects,  chief  among  which  was  the  omission  of  the  central 
suture  which  he  considered,  and  justly  so,  to  be  in  the  way  of  a 
positive  and  efficient  advancement.  Landolt^  thus  described  his 
method  in  1897:  "Conjunctival  incision  close  to  and  parallel 
with  the  corneal  limbus.  No  conjunctival  bridge  for  a  meridional 
suture  is  left,  since  the  muscle  then  becomes  inserted  not  at  the 
corneal  margin,  but  further  back,  corresponding  to  the  conjunctival 
incision.  The  conjunctiva  is  not  detached  far  beyond  the  insertion 
of  the  tendon.  A  small  and  somewhat  flattened  hook  is  passed 
under  the  muscle,  either  according  to  von  Graefe's  method  or, 
better,  after  grasping  the  muscles  with  a  pair  of  forceps^  and  cutting 
a  small  hole.  In  this  manner  the  whole  muscle  is  brought  flat  on 
the  hook,  whereas,  in  the  first  mode,  the  relaxed  muscle  may  be- 
come folded  lengthwise  or  the  hook  become  entangled  in  Tenon's 
capsule  or  the  muscle  fibres.  An  assistant  now  draws  the  muscle 
forward  and  away  from  the  globe  with  the  hook,  and  the  operator, 
with  the  squint  forceps,  grasps  the  muscle  at  a  point  1/3  of  its 
breadth  from  its  margin,  together  with  the  surrounding  connecti\  e 
tissue  and  Tenon's  capsule,  behind  the  hook,  and  then  passes  a  fine 
curved  needle  through  this  entire  fold.  After  this  is  done  on  both 
sides  of  the  muscle,  it  is  pulled  up  by  the  four  threads  and  cut  be- 

^Comptes  rendus  de  ma  clinique  pour  I'annee,  1878. 
'^  Knapp'^  Archives,  vol.  xxvi,  No.  i .  ,  ,  , 

*  Specially  designed  by  Landolt  for  use  on  the  ocular  muscles,  whose 
teeth  are  placed  obliquely  to  the  long  axis  of  the  instrument. 


172 


OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 


tween  the  threads  and  the  hook.  The  tendinous  stump  is  detached 
close  to  the  eyeball.  This  is  a  small  resection,  which  enhances  the 
eflfect  of  the  advancement  in  moderate  degrees  of  strabismus.  In 
simple  insufficiency  or  small  degrees  of  strabismus,  the  muscle  is 
detached  without  resection.  In  strabismus  of  high  degree,  the 
sutures  are  introduced  far  behind  the  insertion  for  a  more  extensive 
resection.  This  done,  the  operator  sees  if  the  sutures  are  well 
applied.  If  they  are  not,  he  reapplies  them,  which  is  very  easy, 
since  the  inferior  surface  of  the  muscle  is  now  exposed.  Then  one 
needle  is  passed  for  a  few  mm.  through  the  episcleral  tissue,  close  to 
the  corneal  limbus  above,  while  the  other  is  passed  similarly  below, 
the  muscular  plane.  The  assistant  grasps  the  eyeball  over  the 
antagonistic  muscle  with  a  fixation  forceps  and  rotates  it  toward  the 
muscle  to  be  advanced.  Thus  the  operator  can  tie  both  sutures 
without  much  traction  on  the  enclosed  tissues.  It  is  advisable  to 
half  tie  both  sutures  before  completely  tying  one.  Thus  the  pre- 
ponderance of  the  first  suture  over  the  second  is  avoided.  To 
prevent  confusion,  white  silk  is  used  for  one  and  black  silk  for  the 
other  suture.  The  muscle,  with  its  covering  conjunctiva,  not  un- 
frequently  rests   upon   the   corneal   margin,   where,   of  course,    it 

cannot  insert.  If  the  advanced 
piece  should  encroach  far  on 
the  cornea,  it  may  be  divided 
by  a  cut  into  two  halves,  as  I 
have  done  for  years,  and  both 
halves  will  then  lie  at  the 
corneal  margin.  Generally  the 
advanced  muscle  retracts 
enough  to  furnish  a  more 
favorable  insertion.  After  the 
sutures  are  tied,  the  eyes  are 
irrigated  with  an  aseptic  solution  and  both  are  bandaged.  In  con- 
vergent squint  the  effect  of  the  operation  is  increased  by  paralysis 
of  accommodation.  Therefore  atropin  is  instilled  into  both 
eyes  as  long  as  there  is  any  tendency  to  convergence.  Exclusion 
of  light,  rest,  and  occlusion  of  the  eyes  have  the  same  effect.  The 
binocular  bandage  remains  at  least  five  days,  for  the  healing  of  the 
wound.  In  convergent  squint  it  is  reapplied  for  several  days 
more  for  the  above  reasons.  Then  it  is  replaced  by  .correcting 
convex  glasses.     The  sutures  need  hardlv  ever  be  removed  before 


Fig.  73. — Weber's  single  suture 
operation. 


WEBER  S    MEIHOI)  173 

the  sixth  or  seventh  day.  In  divergent  squint,  accommodation  and 
convergence  assist  the  operation.  As  soon  as  the  advanced  muscles 
are  firmly  attached,  one  eye  is  left  free.  After  one  or  two  weeks 
the  methodical  exercise  of  convergence  may  be  commenced," 
The  father  of  the  single-suture  advancement  was  Adolf  Weber,'  of 
Darmstadt,  who,  in  1873,  contrived  an  ingenious  though  impracti- 
cable procedure  (Fig.  73).  After  uncovering,  picking  up,  and  dividing 
the  tendon  as  did  Critchett,  he  used  a  triple-armed  suture  that 
was  threaded  and  inserted  in  the  following  manner:  A  fine,  curved 
needle  was  put  on  at  each  end  in  the  ordinary  way,  but  at  the  middle 
the  thread  was  doubled  upon  itself  and  passed  thus  through  the  eye 
of  a  somewhat  larger  needle.  While  an  assistant  lifted  the  tendon, 
the  middle  needle  was  passed  through  the  center  of  the  tendon  from 
the  scleral  side,  thence,  also  from  within  outward,  through  the  distal 
conjunctival  flap,  the  loop  pulled  through,  and  the  needle  removed. 
The  other  two  needles  were  carried  forward  beneath  the  conjunctiva, 
one  above,  the  other  below  the  cornea,  and  brought  out  near  the 
vertical  meridian.  They  were  then  carried  back  and  passed  through 
the  loop  from  the  corneal  side.  The  assistant  tlien  released  the 
tendon  from  the  forceps  and  the  muscle  was  drawn  up  by  the 
traction  on  the  two  ends  of  thread  held  together.  When  the 
muscle  had  been  brought  forward  sufficiently  the  two  threads 
were  made  into  a  rather  large  knot  close  against  the  loop  so  that  the 
suture  could  not  slip.-  This 
measure  possesses  three  points 
of  great  merit,  in  that  it  is 
simple,  easy  of  execution,  and, 
best  of  all,  the  tendon  is  drawn 
forward  exactly  in  the  hori- 
zontal meridian.  Unfortun- 
ately, it  has  two  fatal  faults,  I'lf'-  74-— DcWccker's  modification  of  above, 
viz.,     the     thread,     although 

double,  traverses  the  thickness  of  the  tendon  at  only  one  place, 
in  consequence  of  which  not  only  is  it  more  likely  to  cut  out,  but, 
moreover,  the  center  of  the  tendon  is  pulled  forward  in  a  point,  while 
the  lateral  portions  are  thrown  toward  each  other  in  plaits— not 
spread  out  as  it  should  be. 

'  Lit.  Verzeichniss,  No.  6,  p.  415. 

'  Haab,  in  his  "Augenoperationen,"  Mnnich,  1904,  mcnlions  having  seen 
Horner  make  the  Weber  advancement  save  that,  instead  of  putting  both 
ends  of  thread  through  the  loop  from  the  corneal  side,  he  passed  one  end 
from  either  side  and  tied  them  so  as  to  include  the  loop  in  the  knot. 


174 


OPERATIONS  UPON  THE  EXTERNAL  MUSCLES 


DeWecker^  for  a  time  practised  a  modification  of  Weber's 
operation  (Fig.  74).  Instead  of  holding  the  tendon  by  fixation 
forceps  he,  of  course,  used  his  own  double  advancement  hook.  The 
real  change,  however,  consisted  in  the  curious  mode  of  disposing  of 
the  thread.  The  loop  was  drawn  far  through  and  cut.  Thus  there 
were  two  threads  which  the  surgeon  proceeded  to  tie— not  each  end 
to  its  fellow,  but  each  to  the  opposite  end  of  the  other  thread. 

It  will  be  seen  by  the  foregoing  descriptions  that  the  thread  finds 
its  anchorage  above  and  below  the  cornea  save  in  the  Critchett 
operation,  where  there  is,  in  addition,  a  thread  anchored  between 
the  cut  end  of  the  tendon  and  the  cornea.  There  is  another  class 
of  advancement  methods  wherein  the  only  hold  of  the  suture  (or 
sutures) ,  outside  of  that  in  the  tendon,  is  between  the  latter  and  the 
cornea.     A  few  of  the  more  prominent  of  these  will  be  described. 

The  Pulley  Operation  of  Prince. 2— This  is  a  procedure  which, 
modified  by  its  author  at  certain  stages  of  its  existence,  has  stood 
the  test  of  more  than  a  quarter  of  a  century,  and  is  both  efficient  and 
original  (Fig.  75).  Its  early  name,  however,  is  hardly  applicable  to 
its  present  form.  As  he  first  made  the  operation,  and  as  I  had  the 
pleasure  of  seeing  him  perform  it  in  1884  while  on  a  visit  to  Dr. 
Agnew  at  the  Manhattan  Eye  and  Ear  Hospital,  N.  Y.,  while  I  was 
house  surgeon  to  that  institution,  was  thus : 
A  vertical  thread  was  put  firmly  in  the 
episcleral  tissue  close  up  to  the  cornea  on 
the  side  next  the  tendon  to  be  advanced 
• — quilted  in  for  a  distance  of  about  6 
mm.,  and  the  ends,  for  the  moment,  left 
hanging  free.  He  then  exposed  the 
tendon,  clamped  it  with  his  advance- 
ment  forceps,    and  severed  it  close   to 

Fig.  75. — Prince's  first,  or  .  i     i  j     i 

"pulley"  operation.  the  sclera.     While  an  assistant  held  the 

forceps,  a  double-armed  thread  was 
passed,  from  within  outward,  through  the  tendon,  thus  leaving 
a  loop  in  its  under  side.  Then,  while  the  aid  drew  the  tendon 
forward,  one  end  of  the  double-armed  thread  was  laid  at  right 
angles  across  the  buried  thread  at  the  corneal  margin  and  the 
latter  was  tied  snugly  over  it.  In  this  way  was  formed  the  pidley. 
Lastly,  the  two  ends  of  the  other  thread  were  knotted  and  drawn 

'  Ann.  d'oculist,  t.  70,  1873,  225. 

2  St.  Louis  Med.  and  Surg.  Journal,  i88r. 


verhoeff's  method 


175 


taut,  advancing  the  tendon.  In  order  the  more  readily  to 
distinguish  the  threads  the  vertical  one,  or  pulley,  was  white,  the 
other  black.  The  yielding  of  the  outside  portion  of  the  pulley 
and  the  bunching  of  the  tendon  into  a  cone,  seeing  that  the  traction 
was  all  from  a  single  point,  after  a  number  of  years,  caused  the 
author  of  the  measure  to  very  materially  change  and  improve  the 
method  (Fig.  76).  The  pulley  thread  was  omitted,  and  what  had 
been  the  second  stage  of  the  operation,  i.e.,  the  exposing  and  picking 
up  of  the  tendon,  became  the  first.  The  double-armed  thread  was 
put  into  the  tendon  as  before,  whereupon  one  of  the  needles  was 
made  to  traverse  the  tissue  alongside  the  cornea,  as  had  the  old 
pulley  needle,  all  that  was  left  to  do  being  to  knot  and  draw  the 
thread  until  the  desired  turning  of  the  globe  was  achieved. 


Fig.  76. — Prince's  second 
operation. 


Fig.  77  — Verhoeff's  advance- 
ment operation. 


Verhoeff,^  of  Boston,  has  devised  a  one-suture  mode  similar, 
in  most  respects,  to  that  of  Prince,  but  with  one  essential  difference. 
This  has  reference  to  the  fastening  of  the  tendon  to  the  sclera.  In  the 
Prince  operation  the  pull  of  the  two  threads  is  straight  toward  the 
cut  end  of  the  tendon,  whereas,  in  that  of  Verhoeff,  the  greater  portion 
of  the  tendon's  width  is  tied  down  tightly  to  the  underlying  tissue — 
strapped  down,  as  it  were  (Fig.  77).  The  procedure  is  thus  described: 
A  vertical  incision  is  made  in  the  conjunctiva,  about  3  1/2  mm, 
from  the  cornea,  and  that  membrane  undermined  up  to  the  limbus. 
The  tendon  is  exposed,  lifted  and  held  with  the  Prince  advancement 
forceps.  The  flap  of  conjunctiva  next  to  the  cornea  is  retracted,  one 
needle  of  a  double-armed  fine  thread  is  passed,  vertically,  for  a 
distance  of  6  to  8  mm.  through  the  episcleral  tissue,  one  mm.  from  the 
cornea.  At  its  point  of  exit  the  needle  is  again  plowed  for  a  short 
distance    horizontally  toward    the  tendon.     The  lower  needle  is 

'  Oph.  Record,  1901. 


76 


OPEEATIONS  UPON  THE  EXTERNAL  MUSCLES 


made  now  to  take  this  same  horizontal  course.  Both  needles  are 
then  passed  through  the  tendon,  from  the  scleral  side,  at  a  greater 
or  lesser  distance  behind  the  forceps,  according  as  much  or  little 
effect  is  needed.  The  assistant  pulls  the  muscle  forward  the  requi- 
site distance  and  the  thread  is  drawn  up  and  tied.  That  portion 
of  the  tendon  contained  in  the  bite  of  the  forceps  is  cut  off,  the  free 
end  placed  beneath  the  conjunctiva,  and  the  wound  in  this  membrane 
closed  by  a  fine  suture.  The  conjunctival  thread  is  removed  on  the 
fourth  day;  that  in  the  tendon  on  the  eighth.  With  proper  needles 
and  deftness,  a  very  solid  support  can  be  gof  for  the  suture  in  this 

anchorage,  representing,  as  it 
does,  three  sides  of  a  rectangle, 
and  for  the  lower  degrees  of 
squint  it  must  be  an  excellent 
procedure.  For  the  higher  de- 
grees, one  would  suppose  it 
necessitates  considerable  resec- 
tion of  tendon;  ergo,  shortening 
of  the  muscle. 

In  this  class  belongs  also  the 
operation  of  Worth. ^      This  sur- 

FiG.  78. — Worth's  advancement  operation.  ,  r   n  .         a 

'  '  geon    proceeds   as   follows:      A 

vertical  incision  about  1/2  in.  long  is  made  through  conjunctiva 
and  Tenon's  capsule,  its  middle  close  to  the  corneal  margin. 
These  membranes  are  retracted  to  expose  the  tendon.  If  the 
angle  of  the  squint  is  of  high  degree,  the  incision  is  made 
curved,  with  its  convexity  toward  the  cornea,  in  order  to  allow 
the  membranes  to  retract  more  freely.  Prince's  advancement 
forceps  is  introduced,  with  the  toothed  blade  lying  on  the  con- 
junctiva, and  thus  closed.  The  tendon  and  its  underlying  attach- 
ments are  divided  with  scissors  close  to  the  sclera.  Two  needles, 
each  threaded  with  a  double  strand  of  tolerably  thick  thread  that 
has  been  previously  boiled  to  remove  the  extra  coloring  matter, 
then  steeped  in  a  sterilized  mixture  consisting  of  three  parts  of  white 
beeswax  and  five  parts  of  white  vaselin,  are  employed.  While  an 
assistant  holds  up  the  tendon  and  superposed  membranes,  one  of 
the  needles  is  passed  inward  at  A  (Fig.  78),  through  conjunctiva, 
capsule,  and  muscle,  and  brought  out  at  the  under  side  of  the  tendon. 
It  is  again  passed  through  muscle,  capsule  and  conjunctiva,  and 
'  ''Squint,"  London,  1903. 


MOTAIS    METHOD  T77 

brought  out  at  B.  The  l)ilc  of  the  lluTud  thus  cnch)sc^  about  the 
lower  fourth  of  the  muscle  with  its  lench'nous  exj)ansion,  cajjsule,  and 
conjunctiva.  The  other  needle  is  similarly  entered  at  A',  passed 
through  conjunctiva,  capsule,  and  tendon,  and  brought  out  at  the 
under  side.  It  is  then  again  entered  beneath  the  tendon  and  brought 
out  through  the  conjunctiva  at  B',  this  bite  enclosing  the  upper 
fourth  of  the  tendon.  Both  sutures  are  inserted,  before  proceeding 
further,  in  order  that  they  may  be  symmetrically  placed.  The 
ends  of  the  thread  from  A'  and  B'  are  then  knotted  tightly  at  C. 
The  end  bearing  the  needle  is  then  entered  at  D,  passed  through  con- 
junctiva, capsule,  and  tendon,  and  carried  beneath  the  lower  blade 
of  the  Prince  forceps  nearly  to  the  corneal  margin.  The  needle  is 
here  passed  through  the  tough  circumcorneal  fibrous  tissue  and 
brought  out  at  G'.  The  two  ends  of  thread  are  tlien  loosely  tied, 
with  a  single  hitch,  at  H.  The  first  suture  is  tlien  similarly  com- 
pleted. The  anterior  part  of  the  tendon,  capsule,  and  conjunctiva 
are  then  removed  by  the  scissors  just  behind  where  they  are 
grasped  by  the  forceps.  The  gap  is  then  closed  by  tightly  tying 
each  suture  at  H  H,  so  that  the  cut  end  of  the  tendon  is  brought 
nearly  up  to  the  corneal  margin  at  G  G'.  The  longitudinal  position 
on  the  muscle  of  the  knotted  loops  A,  B  and  C,  and  A',  B',  and  C' 
varies  according  to  the  degree  of  rotation  desired. 

The  hold  on  the  tendon  in  this  operation  afforded  by  the  knotted 
arrangement  of  the  sutures  insures  extraordinary  solidity,  but  it  is 
a  question  whether  or  not  a  certain  amount  of  necrosis  would  not 
ensue  from  strangulation.  As  for  the  rest,  the  anchorage  near 
the  cornea,  which  is  of  even  greater  importance,  is  relatively 
slight — much  more  so  than  in  cither  the  Prince  or  the  \'erhoeff 
operations.  Moreover,  the  operation  would  seem  to  be  needlessly 
complex. 

Crosswise  Suture,  or  Ligature,  of  Motais.^ — A  very  solid 
fastening  is  afforded  by  this  method  of  advancement.  A  single, 
double-armed  suture,  of  braided,  black  silk,  is  used;  the  needles 
being  fine,  very  sharp,  and  but  slighdy  curved.  A  vertical  ellipse 
of  the  conjunctiva  is  excised.  A  large  strabismus  hook  is  introduced 
beneath  the  tendon,  and  the  latter  laid  bare  for  a  distance  of  at  least 
6  mm.  from  its  insertion.  While  the  tendon  is  lifted  by  an  assistant 
with  the  hook  one  of  the  needles  is  passed,  from  before  backward, 
through  the  tendon  near  its  upper  border,  and  4  or  5  mm.  from  its 

^  L'Opht.  Provinc,  July,  iqii. 


178 


OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 


insertion  (Fig.  79).  The  same  with  the  other  needle  below.  The 
lower  needle  is  now  made  to  traverse  the  substance  of  the  sclera,  for 
4  mm.,  in  a  vertical  direction,  as  near  as  possible  to  the  limbus,  and 
the  other  is  made  to  do  the  same,  but  about  1.5  mm.  farther  from  the 


Fig. 


yg. — Motais'  advancement  with  the  ligarute  across  the  tendon,  showing  the 
suture  in  place. 


limbus.  The  tendon  is  divided,  flush  with  the  sclera  and,  with  the 
aid  of  the  loops  of  thread,  and  of  advancement  forceps,  the  free  end 
is  drawn  close  to  the  limbus,  the  suture  is  pulled  down  snug,  and  the 
ends  of  thread  are  tied  across  the  tendon  about  2  mm.  from  its 


S; 

'^H?*^,- 

^ 
^ 

1^     . 

--• 

Fig.  80. — Motais' 


iifiit.     The  tendon  has  Ije 
thread  tied  over  (across)  i 


jd,  thawn  up,  and  the 


extremity  (Fig.  80).  The  knot  is  drawn  only  moderately  tight,  as 
the  post-o})erative  swelling  will  sufficiently  increase  the  tension  upon 
the  thread. 

Elschnig's  Method  of  Advancement. — Realizing  how  neces- 
sary to  successful  tendon  advancement  is  a  firm  fastening  to  the  globe, 
and  hesitating  to  make  it  in  the  thin  sclera,  for  fear  of  perforating  it. 


ELSCIIXIC.  S    MKTIIOD 


179 


has  doubtless  caused  many  <)|)luhalmic  sur.ifcons  lo  lake  up  willi 
tucking,  and  other  shortening  operations,  when  their  actual  j^refer- 
encc  was  for  ad\ancement.  'I'o  this  class  Elschnig's  modification  of 
a  method  by  Ohm  should  strongly  appeal.  Ohm  anchored  his 
sutures  in  the  nearer  tendonous  expansions  of  the  vertical  recti 
muscles.  Here  is  Elschnig's  manner  of  procedure  essentially  as  he 
describes  it.     {Ophthalmic  Record,  Dec,  1912.) 

Free  exposure  of  the  muscle  tendon  by  vertical  incision  and  dis- 
section of  the  conjunctiva  (Fig.  81).  The  tendon  is  grasped  with 
toothed  forceps,  and  incised  with  scissors,  though  permitting  the 


Fig.  81. — Elschnig's  method  of  advancement.     Tendon  divided;  central  suture  put 
into  tendon.     Small  cut  in  sclera. 

edges,  or  most  lateral  fibres,  to  remain  adherent  to  Tenon's  capsule. 
A  double-armed  suture  is  passed,  from  before  backward,  through  the 
tendon  and  out  through  the  opening  made  l)y  the  tenotomy.  The 
tendon  is  stretched  by  this  suture  while,  with  the  scissors,  it  is  dis- 
sected absolutely  free  from  the  sclera.  In  the  vertical  meridian, 
and  several  mm.  above  the  limbus,  a  needle,  bearing  number  i 
braided  silk,  is  passed  through  the  conjunctiva  and  superficial  layers 
of  the  sclera,  in  the  direction  of  the  muscle  lo  be  advanced  (Fig.  82). 
Tt  is  then  passed  through  the  upper  edge  of  the  tendon,  somewhat 


i8o 


OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 


behind  and  lateral  to  the  central  suture,  then,  back  beneath  the 
conjunctiva,  superficially  in  the  sclera,  and  the  outer  half  of  the 
insertion  of  the  superior  rectus,  coming  out  through  the  conjunctiva 
5  or  6  mm.  above  the  point  of  entrance.  A  similar  suture  is  applied 
below,  engaging  the  insertion  of  the  inferior  rectus.  The  corneal  lip 
of  the  conjunctival  wound  is  raised  and  a  shallow  cut  is  made  in  the 
sclera  about  3  mm.  from,  and  parallel  with  the  limbus.  Both  needles 
of  the  central,  or  fixation  suture,  are  passed  through  the  outer  layers 
of  the  sclera,  starting  at  this  incision,  and  emerging  at  the  limbus. 


Fig.  82. — Elschnig's  method  of  advancement.     Lateral  sutures  placed.    Central  one 
given  its  scleral  anchorage,  and  all  ready  to  be  tied. 

A  single  surgical  knot  is  now  made  in  this  suture,  but  the  lateral 
sutures  are  tightly  tied;  meanwhile  the  position  and  motility  of  the 
globe  are  carefully  observed.  The  knotting  of  the  central  suture  is 
completed,  and  the  conjunctival  wound  is  closed  with  o  thread. 

Klschnig  has  employed  this  method  for  more  than  twenty  years, 
which  speaks  much  in  its  favor. 

The  Beard  Advancement  Operation  (Figs.  83  and  84). — The 
first  published  account  of  this  procedure  appeared  in  the  American 
Journal  of  Ophthalmology  for  March,  1889.  Within  the  past  three 
or  four  years  several  articles  in  tlie  ()i)]i(halmic  lilcralure  of  Great 


BEARD  S    ADVANCEMENT 


l8l 


Britain  and  the  continent  of  iMirope  Iiave  been  l)roii<j;ht  to  my  no- 
tice, in  which  the  writers  told  of  original  methods  very  similar  to,  and 
in  one  case — viz.,  Dr.  H.  Lindo  Ferguson^ — practically  identical  with 
this,  though  it  is  a  pleasant  reflection  that  they  all  lack  priority. 

In  most  instances  the  first  part  of  the  operation  consists  in  the 
making  of  the  neatest  possible  buttonhole,  as  per  description  on 
I)age  163  of  the  tendon  of  the  muscle  opposite  to  that  which  is  to  be 
advanced.  The  sole  object  of  this  i)artial  tenotomy  is  to  cause  a 
temporary  breaking  of  the  power  of 
that  muscle,  so  that  the  advanced 
tendon  may  have  a  relatively  undis- 
turbed period  during  which  to  make 
its  new^  insertion.  The  tiny  scissors 
and  hooks  of  Dr.  Stevens,  of  New 
York,  are  employed. 

The  patient  is  told  to  look  far 
to  the  opposite  side;  with  mouse- 
tooth  forceps  the  conjunctiva,  and 

only   this    membrane,    is    picked    up  F1G.83.— Beam  s  advancement  oper- 

ation.      The    tinv    dotted    oval    is    to 
m   a  vertical   fold,  well  back  of  the     represent   spot    Where  tendon  was  at- 

insertion  of  the  muscle;  with  small,    S'thSfi  'r'a'^cS  'i^:!^. 

straight     scissors,    slightly    blunted     The  tendon  is  never  laid  bare  as  this 
,  .  .      ^  ,  drawing  would  indicate. 

at  the  pomts,  a  snip  is  made  across 

the  fold,  exactly  over  the  center  of  the  tendon,  and  the  incision 
thus  begun  is  carried  forward  horizontally  till  it  reaches  the 
margin  of  the  cornea.  Then  the  episcleral  tissue  forward  of  the 
insertion  of  the  tendon,  if  there  be  enough  of  it,  is  in  like  manner 
incised,  so  that  a  furrow  is  opened,  whose  bottom  is  the  naked 
sclera,  and  along  which  the  cut  tendon  is  to  slide.  By  so  doing,  one 
reaches  the  tendon  by  positive  stages,  neatly  and  discriminately,  and 
avoids  giving  it  an  unguarded  snip,  which  is  possible  with  too 
heroic  cutting.  The  tendon,  lightly  covered  by  its  aponeurosis, - 
being  now  well  in  view,  is  slightly  lifted  by  the  forceps,  and  a 
medium-size  squint-hook  inserted  beneath  it,  as  close  as  can  be  to 
the  insertion.  No  advancement  forceps  is  put  on  to  mangle  the 
tendon — an  assistant  holding  the  hook  until  the  suture  is  placed. 


'  Transactions  of  the  Ophthalmic  Society  of  the  United  Kingdom,  vol. 
xvii,  p.  336. 

*  In  striving  for  marked  effect  one  must  be  careful  to  avoid  undue 
advancement  of  Tenon's  capsule.  This  means  tightening  of  the  check 
ligament  on  that  side  and  consequent  restriction  of  motility. 


152  OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 

This  last  is  of  No,  i  braided  black  silk,  boiled  in  equal  parts  of 
paraffin  and  vaselin,  and  is  double-armed — i.e.,  has  a  needle  at 
each  end.  Some  operators  would  prefer  catgut,  of  a  corresponding 
size.  This  may  be  so  prepared  as  to  be  absorbed  in  say  ten  days, 
and  has  the  great  advantage  of  not  requiring  removal.  The  black 
thread,  however,  facilitates  the  operation  by  its  greater  visibility. 
The  needles  are  as  fine  as  will  barely  carry  the  thread,  and  are  straight 
two-thirds  of  the  way  from  eye  to  point,  from  thence  slightly  curved. 
As  a  necessary  precaution,  the  needles  should  be  tested  to  see  that 
they  are  quite  sharp,  and  their  points  be  examined  under  a  magni- 
fying glass  to  make  sure  that  they  are  without  flaws.     Both  needles 


Fig.  84. — Beard's  advancement. 


are  passed  downward  through  the  tendon  (see  Fig.  St,),  at  a  distance 
from  its  insertion  proportionate  to  the  degree  of  effect  desired,  one 
near  the  upper,  the  other  near  the  lower  border,  and  the  loop  or 
stitch  thus  formed  is  drawn  down  snugly  upon  the  tendon.  Then, 
taking  the  upper  needle  in  the  holder,  the  conjunctiva  and  anterior 
capsule  are  lifted  by  the  forceps,  and  the  needle  passed  beneath 
these  membranes  without  entering  them,  carried  well  forward,  then 


beard's  advancement  183 

plunged  into  the  episcleral  and  superficially  into  the  scleral  tissues, 
and  plowed  along  until  a  point  is  reached  opposite  the  vertical 
meridian  of  the  cornea,  or  beyond,  and  fully  four  to  five  millimeters 
from  the  limbus,  where  the  needle  is  brought  out.  The  lines  of 
anchorage  should  be  divergent,  not  horizcjnlal.  Merely  placing 
the  suture  beneath  the  membranous  covering  of  the  globe  will  not 
suffice;  a  much  firmer  sujjport  is  required.  Nothwithstanding  the 
sharpness  of  the  needles,  no  little  exertion  is  needed  to  force  them 
through  the  dense  fibrous  tissue,  and  in  doing  so  the  globe  must  be 
steadied.  To  grasp  the  conjunctiva  and  capule,  to  this  end,  will 
not  do,  as  these  membranes  will  tear;  so  I  take  hold  with  strong  broad- 
jawed  forceps  of  the  tendon  at  its  insertion,  even  including  the  hook 
as  held  by  the  assistant.  Precisely  the  same  is  done  by  the  other 
needle  below.  Now,  obviously,  if  the  ends  of  the  thread  were  here 
tied,  the  suture  would  lie  across  the  cornea;  instead,  however,  the 
upper  needle  is  again  placed  in  the  holder  and  passed  from  behind, 
under  the  loop  or  stitch  that  lies  vertically  on  the  tendon  (see  Fig.  83) , 
and  one  must  be  quite  sure  that  the  needle  passes  under  the  thread, 
and  not  through,  even  the  least  strand  or  fibre  of  it;  for  this  would 
cause  a  snarl  in  drawing  up  the  suture,  and  do  away  with  one  great 
feature  of  this  operation — that  of  a  perfect  sliding  suture.  To  make 
sure,  we  had  better  include  a  little  of  the  tendon  here,  or  else  leave  the 
loop  standing  up  a  little,  so  that  we  may  see  clearly  what  we  are  doing. 
It  is  better  to  make  an  invariable  rule  of  using  the  upper  thread  for 
this  step — as,  in  the  first  place,  the  knot  does  not  lie  beneath  the 
sensitive  upper  lid,  and,  in  the  second,  the  removal  of  the  suture  is 
made  simpler  and  easier.  One  now  proceeds  to  divide  the  tendon. 
The  thread  is  gotten  out  of  the  way  of  the  scissors;  if  need  be, 
held  out  of  the  way  by  an  assistant  with  a  strabismus  hook;  for  to 
cut  it  in  two  were  awkward  in  the  extreme.  The  hook  beneath  the 
tendon  is  taken  by  the  operator,  and  the  tendon  is  completely 
severed;  next,  the  stump  of  tendon  at  its  insertion  is  seized  by 
the  forceps  and  cut  off  even  with  the  sclera.  The  latter  step 
serves  two  very  important  purposes — it  removes  an  obstacle  to  the 
sliding  forward  of  the  tendon,  and  i)re\cnts  an  unsightly  lump  at 
the  site  of  the  operation.  Then,  as  to  the  tying  and  tightening  of 
the  suture,  several  points  must  be  observed.  One  should  have 
his  assistant  rotate  the  eye  toward  the  operated  muscle  by  means  of 
fixation  forceps.  It  is  essential  that  the  loop  across  the  tendon 
should  remain  tightly  drawn  down;  to  insure  this,  and  at  the  same 


1 84        OPERATIONS  UPON  THE  EXTERNAL  MUSCLES 

time  obviate  any  tearing  up  of  the  track  of  the  suture  where  it  lies 
deeply  imbedded  under  the  conjunctiva,  take  hold  of  the  upper 
end  of  thread  with  the  dressing  forceps,  and  the  lower  one  with 
the  fingers,  just  where  it  emerges  above  and  below  the  cornea, 
and  pull,  not  back  in  the  direction  of  the  advancing  muscle,  but 
away  from  it  (in  Fig.  84,  toward  the  nose) .  This  insures  drawing  the 
muscle  forward  in  a  straight  line.  Having  in  this  way  drawn  the 
muscle  well  forward,  the  assistant  "takes  up  the  slack"  of  the  end 
of  the  thread  which  passes  beneath  the  loop,  gives  it  to  the  operator, 
who  lets  go  with  his  dressing  forceps,  and  ties  the  suture. 

The  tension  being  equal  on  all  the  thread-bearings,  the  advancing 
tendon  is  drawn  neither  up  nor  down,  but  comes  forward  in  a 
straight  horizontal  line.  One  may  leave  the  suture  tied  in  a  long 
bow-knot,  after  Prince,  the  shorter  end  of  the  thread  being  always 
the  one  which  controls  the  loop,  so  that  after  the  lapse  of  twenty- 
four  hours,  if,  for  any  reason,  there  is  occasion  for  modifying  the 
effect  upon  the  eye,  the  last  part  of  the  knot  may  be  untied,  and  the 
suture  either  tightened  or  slackened,  as  desired;  and  in  any  but 
dispensary  practice  this  will  do  excellently.  On  first  removing  the 
bandage,  whether  one  wishes  to  shift  the  suture  or  not,  the  long  ends 
and  loop  of  thread,  which  have  been  till  now  fixed  by  the  dressing 
just  outside  the  nearest  canthus,  are,  before  rebandaging,  cut  off 
close  to  the  knot.  The  suture  is  allowed  to  remain  in  the  eye  from 
six  to  nine  days— the  dressing  being  renewed  during  the  time 
at  intervals  of  about  forty-eight  hours.  Both  eyes  should  be 
bandaged,  and  absolute  rest  in  bed  for  at  least  forty-eight  hours 
must  be  insisted  upon. 

I  have  abundantly  proven  that  the  pull  of  the  suture  in  the  tendon 
is  not  only  to  move  and  hold  the  muscle  forward,  but  also  to  keep 
the  tendon  spread  out  flat.  This  is  easily  demonstrated  by  a  model 
— even  with  the  flimsiest  material  to  represent  the  tendon. 

Some  few  of  my  confreres,  on  reading  as  to  the  technic  of  the 
advancement  operation  herein  detailed,  have  conceived  a  notion 
that  it  is  complicated  and  difficult.  This  impression  has  doubtless 
arisen  from  my  having  dwelt  at  such  length  upon  the  minutia;  of 
the  operation,  which  alone  insure  success.  As  a  matter  of  fact,  it  is 
one  of  the  simplest  of  procedures.  It  is,  moreover,  one  of  the 
safest.  There  is  usually  some  superficial  reaction,  but  in  all  my 
experience  I  have  seen  but  a  single  case  which  promised  trouble. 
This  was  that  of  a  dispensary  patient,  who  reported  on  the  fourth 


CAPSULAR    ADVANCEMENT  185 

day  after  the  operation  with  septic  tenonitis  at  the  site  of  the  in- 
cision. The  process  was  promptly  arrested  before  any  damage 
resulted.  My  experience  with  the  operation  refers  to  a  great 
number  of  cases,  many  of  which  I  have  had  under  observation  for 
from  live  to  twenty  years,  and  I  can  afhrm  that  the  results  have 
been  most  gratifying,  both  to  patients  and  to  operators.  I  would, 
therefore,  confidently  and  heartily  recommend  it  to  the  profession. 
The  day  of  the  tenotomy,  pure  and  simple,  as  a  rational  remedy  for 
the  cure  of  strabismus  is  past.  Its  mangled  victims  have  too  long 
paraded  their  horrors,  such  as  the  paralyzed  muscle,  the  secondary 
squint,  the  retracted  caruncle,  and  the  ghastly  exophthalmos. 

3.  Capsular  Advancement. — In  the  hope  of  doing  away  with 
the  annoyance  caused  by  the  cutting  out  of  the  thread  and  the 
escape  of  the  muscle  in  the  advancement  operation,  at  a  time  when 
it  was  the  custom  to  completely  denude  the  tendon,  DeWeckeri 
proposed  his  advancement  capsnlaire,  which,  even  at  the  hands  of  its 
inventor,  enjoyed  but  an  ephemeral  existence.  The  idea  was  that, 
by  advancing  the  adjacent  check  ligament  or,  in  the  plural,  as 
the  French  put  it,  les  ailerons  capsulaires,  or  lateral  capsular  expan- 
sions of  the  tendon,  the  muscle  would  be  supported  and  strengthened, 
and  the  end  would  be  accomplished  without  touching  the  tendon. 
Here  is  how  he  proceeded:  First,  the  excision  of  a  semilunar  or 
pyramidal-shaped  piece  of  conjunctiva,  base  toward  the  cornea, 
over  the  insertion  of  the  tendon,  about  lo  mm.  high  and  5  wide, 
and  a  corresponding  portion  of  Tenon's  capsule;  then  detached  the 
tendon  from  its  capsular  sheath  all  around,  undermined  the  con- 
junctiva up  to  and  around  the  neighboring  half  of  the  cornea,  and, 
lastly,  drew  the  capsule  forward  and  secured  it  by  two  sutures  ar- 
ranged much  as  are  the  outer  threads  in  the  Critchett  advancement, 
the  difference  being  that  the  tendon  was  left  untouched,  as  it  was  not 
expected  to  move,  but  merely  to  allow  the  capsule  to  slip  forward  over 
it.  The  effect  was  dosed  by  the  dimensions  given  to  the  excised 
portions  and  the  size  of  the  bite  of  the  thread  in  the  capsule.  De- 
Wecker  practised  making  of  this  operation  for  several  years.  The 
writer  saw  much  of  this  gifted  surgeon's  work  in  the  years  1885 
and  1886,  during  which  time  he  met  Herman  Knapp,  who  made  a 
long  visit  to  Paris  in  the  latter  year.  Knapp  became  impressed  by 
DeWecker's  enthusiasm  over  the  measure  and,  on  returning  to 
New  York,  "  made  the  operation  a  few  times.     The  effect  proving  in- 

'  Annal  d'oculist,  t.  xc,  p.  188,  1883. 


i86 


OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 


Fig   S; 


-Knapp's  musculo-capsular 
advancement. 


sufficient,  I  at  once  modified  it  in  such  a  way  that  it  was  in  reality 
a  tendino-capsular  advancement."  ^  Knapp  told  of  his  modifica- 
tion at  the  meeting  of  the  American  Ophthalmological  Society  in 
1886,  and  the  first  published  account  of  it  appeared  in  the  transac- 
tions of  this  society  for  that  year. 
DeWecker  very  soon  abandoned 
the  original  operation  and 
adopted  what  is  practically 
Knapp's  modification  (Fig.  85), 
Here  is  Knapp's  description 
of  it  in  Norris  and  Oliver's  sys- 
tem, page  876:  "The  conjunc- 
tiva is  vertically  incised  over  the 
insertion  of  the  tendon,  and 
undermined  around  the  cornea 
to  the  vertical  meridian; 
Tenon's  capsule  opened  with  the  scissors  at  the  lower  line  of  the 
insertion  line  of  the  tendon,  a  strabismus  hook  slipped  beneath 
the  tendon  and  the  capsule  incised  over  the  tip  of  the  hook  on 
the  upper  side  of  the  tendon.  Three  or  four  sutures  are  applied, 
one  through  the  conjunctiva  and  the  lower  edge  of  the  muscle, 
passing  under  the  conjunctiva  obliquely  forward,  then  two  or  three 
millimeters  through  the  outer  layers  of  the  sclera  immediately  before 
emerging  on  the  conjunctiva  near  the  vertical  meridian.  The  second 
suture  is  on  the  upper  side,  and  pursues  a  course  analogous  to  the 
first.  The  third  suture  is  passed  through  the  conjunctiva  and  the 
middle  of  the  muscle,  advanced  under  the  hook,  which  during  the 
application  of  all  the  sutures  raises  the  tendon,  thrust  through  the 
middle  of  the  tendon  near  its  insertion,  then  through  the  superficial 
layers  of  the  sclerotic  to  emerge  on  the  conjunctiva  near  the  cornea. 
If  a  large  effect  is  desired,  a  fourth  suture  is  applied  at  the  side  of, 
and  similar  to,  the  third.  The  sutures  are  tied  in  the  same  way  as 
in  Critchett's  advancement.  The  operation,  in  fact,  is  the  same 
as  Critchett's  without  excision  of  a  piece  of  tendon.  The  sutures 
remain  in  five  or  six  days.  The  operation  acts  by  shortening 
(tightening)  the  check-ligaments  and  the  muscle  by  folding  them. 
They  remain  folded  and  attached  to  their  new  position  on  the 
sclerotic  by  means  of  cicatricial  tissue,  which  is  formed  by  an  ad- 
hesive inflammation  due  to  the  irritation  set  up  by  the  sutures." 
*  Quoted  from  Knapp  in  Norris  and  Oliver,  p.  S76. 


TENDON    TICKIXG 


187 


4.  Tendon  shortening,  for  the  cure  of  the  various  forms  of 
squint  has  been,  and  still  is,  extensively  practised.  As  has  been 
stated,  this  is  accomplished  in  two  ways:  (a)  by  folding  of  the  tendon 
upon  itself  and  fixing  it  so,  or  tucking;  and  (b)  by  the  excision  of  a 
portion  of  the  tendon — tcnoncctomy. 

a.  Folding  or  tucking  of  the  tendon  is  the  outgrowth  of 
DeWecker's  capsular  advancement,  treated  of  in  the  preceding 
section,  and,  as  there  asserted,  it  was  Herman  Knapp,  of  New  York, 
who  was  the  originator  of  the  measure  under  the  name  of  tendino- 
capsular  advancement. 

Kalt^  proposed  a  modification 
of  Knapp's  method,  which  con- 
sisted in  omitting  the  tendon 
from  the  thread,  but  putting  it 
in  capsule  only,  as  did  DeWecker 
in  his  capsular  advancement. 
The  sheath  of  the  tendon  was 
not  loosened,  but  to  avoid  folding 
the  tendon  he  severed  the  latter 
from  the  globe  and  allowed  it  to 
advance  with  the  capsule. 

Lagleyze,2  of  Buenos  Ayres,  reports  excellent  results  obtained  with 
a  folding  operation  of  his  own  (Fig.  86)  made  as  follows:  After 
having  excised  a  flap  of  conjunctiva  overlying  the  tendon,  he  incises 
Tenon's  capsule,  inserts  one  strabismus  hook  beneath  the  tendon  and 
another  beneath  the  fleshy  part  of  the  muscle.  He  then  proceeds  to 
suture  by  means  of  a  double-armed  thread.  One  needle  is  made  to 
pass  through  the  body  of  the  muscle  from  its  scleral  surface,  i  mm. 
from  its  border  and,  in  emerging,  to  include  the  capsule  and  con- 
junctiva; the  other  needle  follows  the  same  course  near  the  other 
border.  The  loop  of  thread  thus  rests  on  the  fleshy  portion  of  the 
muscle.  The  needles  are  then  carried  forward  and  the  ends  of 
thread  given  secure  anchorages  near  the  cornea.  In  proportion  as 
the  thread  is  drawn  up,  the  strabismus  diminishes.  The  thread 
is  removed  at  the  end  of  12  days.  Obviously,  this  operation 
can  be  made  applicable  only  to  the  lower  degrees  of  squint. 

So  numerous  have  been  the  original  folding,  or  tucking,  operations 
that  have  been  given  to  the  world  since  those  just  mentioned,  and, 


Fig.  86.— Lagleyze's    folding 
method. 


Soc.  d'opht.,  2  mars,  1891. 
Arch,  d'opht.,  xii,  p.  668,  1892. 


l88        OPERATIONS  UPON  THE  EXTERNAL  MUSCLES 

as  only  a  somewhat  elaborate  or  detailed  description  in  each  instance 
could  give  an  adequate  idea  of  its  merits — and  merit  they  have, 
almost  without  exception — it  is  inexpedient  to  more  than  refer  to 
some  of  them  here. 

Colburn,^  of  Chicago,  some  twelve  years  ago  gave  what  he 
called  an  "  advancing  tuck  operation." 

Savage,  2  of  Nashville,  devised  a  muscle-tucking  operation  more 
than  ten  years  ago.  Again, ^  about  one  year  ago  the  same  surgeon 
published  another  tendon-folding  measure. 

It  seems  that  a  classification  of  these  procedures  is  made  into  the 
"shortening  tuck,"  i.e.,  where  the  fold  is  made  at  or  behind  the 
insertion  of  the  tendon;  and  the  "advancing  tuck"  where  the  same 
is  formed  between  the  insertion  and  the  cornea. 

Todd,"*  of  Minneapolis,  and  Clark,  of  Columbus,  have  not  only 
given  tucking  operations,  but  each  has  invented  an  ingenious  tucking 
instrument.  Todd's  is  a  kind  of  two-tined  fork,  or  bident,  one 
prong  of  which  is  placed  beneath  the  tendon  and  there  clamped  by 
turning  a  nut  on  the  handle — to  rotate  the  instrument  backward 
makes  the  shortening  tuck,  and  forward,  the  advancing  tuck  (Plate 
VII,  No.  87).  The  Clark  device  is  a  triple  squint  hook,  the  middle 
member  of  which  is  made  to  move  up  or  down  by  turning  a  knob  on 
the  handle.  When  the  three  members  are  on  the  same  level,  the 
instrument  appears  only  as  a  rather  broad  hook.  To  apply  it,  the 
middle  portion  is  placed  somewhat  below  the  other  two,  introduced 
beneath  the  tendon,  while  the  other  two  rest  on  top  of  the  tendon. 
The  middle  is  then  made  to  rise,  whereby  a  fold  of  the  desired  height 
is  formed.  In  each  case  the  folds  of  tendon  are  sewn  together  by 
animal  sutures  to  prevent  unrolling. 

Bruns,^  of  New  Orleans,  is  also  the  author  of  a  clever  folding 
operation,  and  has  contrived  a  modification  of  the  Clark  hook  to 
meet  the  requirements  of  the  proceeding. 

A  truly  cavalier  folding  operation  is  that  of  Trousseau.*^  Given 
a  convergent  squint,  for  example,  after  moderate  tenotomy  of  the 
internus,  an  aid  rotates  the  globe  far  inward,  the  tendon  of  the 
externus  is  grasped  by  fixation  forceps  and  drawn  away  from  the 

'  Oph.  Record,  April,  1902. 
2  Oph.  Record,  Marcli,  1893. 
'Oph.  Record,  Nov.,  1903. 

'  Oph.  Record,  vol.  xi,  p.  73,  1902,  and  Annals  of  Oph.,  Oct.,  1904;  also 
Journal  Am    Med.  Assn.,  Jan.  7,  1905. 
*  Oph.  Record,  June,  1904. 
"  Annal  d'oculistique,  Jan.,  1903. 


RESECTION    OF    TENDON  189 

globe.  A  long,  curved  peedle  and  subsUmlial  thread  are  passed 
into  the  episcleral  tissues  near  the  cornea,  through  the  tendon, 
then  beneath  the  body  of  the  muscle,  Jinally  through  it  and  out. 
The  eye  is  then  rotated  lo  Ihc  outer  angle  and  the  suture  tied.  The 
thread  remains  from  6  to  12  days.  In  27  cases  the  results  were 
satisfactory  in  21. 

Other  European  originators  of 
folding  operations  arc  Brand  ^  and 
Foster. 2  The  latter's  is  very  like  the 
Schweigger  resection  operation  in  all 
save  that,  of  course,  the  tendon  is  not 
divided. 

There  is  one  feature  wherein  the  Fig.  87.— j.  f.  Novcs'  sh<)I■u•nill<,^ 
folding  methods  are  unique — if  they 

do  not  succeed  in  correcting  the  deviation,  they  cannot  leave  it 
greater  than  it  had  been  before. 

The  strabismus  operation  of  J.  F.  Noyes,^  of  Detroit,  has  been 
referred  to  as  a  folding  operation  (Fig.  87).  It  was,  in  truth,  a 
shortening  operation — not,  however,  by  folding  nor  by  resection  of 
the  tendon,  but  by  dividing  and  lapping  it.  The  whole  width  of  the 
tendon  was  cut  through  at  a  distance  from  its  insertion  that  varied  in 
accordance  with  the  degree  of  squint;  the  distal  end  was  placed 
beneath  the  stump,  and  the  tw^o  sewed  together. 

b.  Shortening  by  excision  of  a  part  of  the  tendon — resection — 
tenonectomy — as  an  adjunct  to  the  rest  of  the  procedure  has  been 
employed,  in  some  measure,  by  almost  every  ophthalmic  surgeon 
who  ever  made  a  veritable  advancement  operation,  but  as  a  single 
measure  it  has  not  been  given  wide  appHcation.  For  my  part, 
I  beheve  it  to  be  a  measure  that  deserves  more  consideration  in  the 
professional  mind  than  it  enjoys — in  this  country,  at  least.  Surely, 
it  is  as  much  to  be  commended  as  is  the  operation  of  tendon  folding. 
Yet  were  its  popitlarity  commensurate  with  the  number  of  different 
modes  that  have  been  proposed  for  the  performance  of  it,  its  place 
in  ophthalmology  were  assured.  On  the  continent  of  Europe 
resection  does  not  go  abegging. 

One  of  the  first  to  give  prominence  to  such  muscle  shortening 
was  Vieusse,^  who  cut  tlie  tendon  a  short  distance  behind  its  inser- 

'  A.  F.  A.,  1902. 

2  Versammlung.  der  Niederl.  Ophthl.  GescUsch.,  Doc,  1901. 

'  Trans,  of  the  Am.  Oph.  Society,  1874,  p.  273. 

"*  Record  d'opht.,  1875,  p.  330. 


igo  OPERATIONS    UPON   THE    EXTERNAL   MUSCLES 

tion,  abscised  from  the  posterior  portion  what  was  requisite  for  the 
case,  and  united  the  cut  ends  by  two  sutures. 

Probably  the  most  extensively  practised  of  any  resection  to  date 
is  that  of  Schweiggeri  (pig,  gg).  After  tenotomy  of  the  opposite 
muscle  a  horizontal  incision  is  made  through  conjunctiva  and  cap- 
sule, over  the  center  of  the  tendon  to  be  excised.  A  fiat,  curved 
hook  is  inserted  beneath  the  tendon  and  shoved  back  and  forth 
to  free  and  spread  it  out.  A  second  hook  is  then  inserted,  but  from 
the  opposite  side.  While  one  hook  is  pushed  up  snug  against  the 
insertion,  the  other  is  pushed  backward  till  from  8  to  lo  mm.  of  the 
tendon  are  exposed.  With  the  help  of  an  aid,  the  amount  of  tendon 
to  be  resected  is  measured  off  with  a  tiny  tape,  something  hke  a 

strabometer— also  Schweig- 
jl  ger's       invention — bearing 

//  ^;:^^^  a  mm.  scale  whose  zero  is 

^-^f^"^^ — '':^Ci/^       ^^  ^^     ^^^     center,    and    the 

Pt^--^^/\   /     /^~^     \  points    marked    by    slight 

\    *il^  ^  )l      V_y     /  nicks    in    the   edge  of  the 

""W^-  -  '^^^^^V\V.-__,.^  tendon.     Two     double- 

^?^       VV  armed  catgut    sutures  are 

^;y^  ^^  ready.     These  are  put  in, 

Fig.  8S.—Schweigger's  resection  operation         one    Or    twO    mm.    back    of 
for  squint.  .  .   ,  , 

the  posterior  nick;  the 
needle  of  one  suture  is  drawn  through  close  to  the  upper  border, 
carried  beneath  to  a  point  slightly  below  the  center,  then  up  through. 
Now,  a  needle  of  the  second  thread  is  drawn  through  near  the  lower 
border,  carried  up  under,  and  out  just  above  the  center.  Each 
suture  is  tied,  thus  ligating  the  entire  tendon.  The  four  threads 
are  held  by  an  assistant,  the  tendon  is  cut  at  the  posterior  nick, 
the  stump  is  lifted  by  forceps,  the  four  needles  passed  through  it 
from  the  scleral  side,  close  up  to  the  insertion,  the  tendon  is  cut  off 
at  the  other  nick,  thus  completing  the*  resection,  the  sutures  are 
drawn  so  as  to  butt  one  end  of  tendon  against  the  other,  and  tied. 
The  outer  wound  is  closed  with  silk  thread. 

Another  such  shortening  measure  is  the  "Myectomy"  of  L. 
Miiller,  the  main  points  of  which  are  thus:  The  operation  is  made 
under  narcosis  to  relax  the  muscle.  Bilateral  tenotomy  of  ih^Shid- 
miiskel.  Vertical  incision  of  conjunctiva  4  mm.  from  the  cornea, 
and  the  wound  well  retraclcd  to  lay  bare  the  tendon.     The  latter  was 

'  A.  F.  A.,  29,  p.  165,  1894. 


TKNDOX    SIlOklllNlXC.  IQI 

lifted  on  the  hook  at  u  dislancc  behind  the  insertion  c()ri-es])()n(hng 
to  the  length  of  the  ))iecc  to  be  exeised,  which,  in  divergent  s([uint, 
this  surgeon  states,  would  be  from  6  to  8  mm.,  and  for  convergent, 
somewhat  less.  The  proposed  section  is  so  measured  on  the  tendon 
by  means  of  small  compasses,  and  so  marked  as  to  leave  a  2  mm. 
stump  at  the  insertion.  Close  behind  the  piece  to  be  resected  are 
placed  the  sutures  of  rather  coarse  silk,  one  near  the  upper,  the 
other  near  the  lower  border,  each  including  about  1/4  of  the  width 
of  the  tendon,  and  tied.  The  ends  bearing  the  needles  are  cut  off 
close  to  the  knots.  While  an  aid  holds  the  threads,  the  tendon  is 
cut  at  the  distal  mark,  and  two  other  silk  threads  are  put  into  the 
stump  close  to  the  sclera  and  in  the  same  way  as  were  the  other  two, 
cutting  off  the  needle  ends.  The  tendon  is  now  cut  at  the  proximal 
mark  and  the  opposite  ends  of  the  thread  are  tied  in  surgeons' 
knots,  at  the  same  time  approximating  the  ends  of  tendon.  The 
outer  wound  is  closed  by  live  sutures,  and  the  buried  threads  are 
left  in  for  all  time. 

In  comparing  resection  with  advancement,  jNliiller  affirms  that 
the  latter  finds  no  analogue  in  surgery,  and  is  a  very  imperfect 
procedure,  for  the  reason  that  one  does  not  know  how^  much  the 
yielding  conjunctiva  will,  during  the  first  24  hours,  permit  the  muscle 
to  retract.  Consequently,  one  must  always  aim  for  a  primary 
over-effect  without  knowing  how  much  of  it  will  disappear.  j\Iore- 
over,  he  believes  it  of  the  greatest  importance  that  the  original  point 
of  insertion  be  left  intact,  to  prevent  an  oblique  attachment,  which 
could  occur  through  sliding  about  of  the  advanced  tendon. 

It  is  evident  that  the  foregoing  remarks  do  not  refer  to  that  form 
of  advancement  in  which  a  solid  anchorage  is  obtained  for  the  thread 
in  episcleral  or  in  scleral  tissue. 

The  Beard  Shortening  Operation.— Fig.  89  illustrates  an 
operation  devised  by  the  author^  some  time  ago,  which  is  adapted 
to  certain  cases  where  shortening  of  the  muscle,  and  not  advance- 
ment, is  desired;  though  I  must  admit  I  have  rarely  found  occa- 
sion to  practise  it.  The  tendon  of  the  opposite  muscle  is  button- 
holed, as  if  for  the  advancement  operation.  Here  also  the  suture 
is  a  double-armed  one,  the  needles  being  of  a  half-curved  variety 
and  very  sharp.  The  primary  incision  is  the  same  as  in  the  ad- 
vancement, though  here  the  tendon  is  laid  bare.  In  this  operation 
the  advancement  forceps   must  ])e  used.     Tliis    instrument   hxes 

'American  Journal  of  Ophthalmology,  March,  iSSg. 


ig: 


OPERATIONS  UPON  THE  EXTERNAL  MUSCLES 


the  tendon  midway  of  the  i)arallelogram  included  between  the 
\-ertical  h'nes  (Fig.  89),  which,  of  course,  varies  in  length  ac- 
cording to  the  degree  of  shortening  needed.  The  tendon  is 
then  di^■ided  at  the  point  occupied  by  the  line  near  the  cornea, 
and  the  forceps  given  to  an  assistant.  Catching  hold  of  the 
stump  of  tendon  with  mouse-toothed  forceps,  the  needles  are 
passed  down  through  the  insertion,  hugging  the  sclera,  one 
near  the  upper,  the  other  near  the  lower  border.  They  are 
then  carried  beneath  the  tendon,  without  crossing  the  thread,  and 
brought  out  correspondingly  from  below^,  and  far  enough  back 
of  the  fixing  forceps  to  insure  a  firm  hold;  the  loop,  however,  is 
not  drawn  down,  but  is  left  very  long,  as  shown  in  the  drawing. 
Here  the  operator  takes  the  forceps  from  the  assistant  and  cuts  the 

tendon  at  the  point  indicated  by 
the  other  vertical  line,  thus  re- 
secting a  portion.  The  long 
loop  and  the  two  ends  of  thread 
are  then  tied  in  one  knot,  and 
the  cut  ends  of  the  tendon 
nicely  butted  together.  If  the 
surgeon  prefers,  the  loop  may 
be  cut  and  the  ends  tied  sepa- 
rately. The  thread  may  be  ab- 
sorbable or  not,  as  the  operator 
chooses.  The  wound  in  the 
membranes  is  closed  by  one  or 
two  fine  sutures.  The  points 
claimed  for  this  over  certain  other  shortening  operations  lie  in  the 
facts  that  the  thread  embraces  and  supports  the  united  ends  of 
the  tendon,  both  in  front  and  behind,  so  that  they  are  kept  in 
nice  apposition,  and  not  inclined  to  stand  up  in  a  pout,  and  that 
the  operation  is  simple  and  easy  of  execution. 

Among  others  who  have  designed  practicable  resection  operations 
are  Driver, ^  Coates,^  Baraquez,^  Prince,"  and  Stevens.^ 

5.  Tendon  Recession.— In  tlic  writer's  opinion,   tlicre  is  but 
one  class  of  scpiint  cases  wherein  the  surgical  treatment  calls  for  an 


Fig.  89. — Beard's  shortening  operation. 


'  Kl.  MbL  f.  Aug.,  ]).  133,  1876. 

-  Lancet,  I\Iay,  1878. 

^  BoUetin  de  Clin.  oft.  de  Santa  Cruz,  No. 

^Journal  of  tlic  Am.  Med.  Assn.,  Oct.  m, 

•''N.  Y.  Med.  jour.,  ],.  345,  1889. 


i8S^. 


TKXDOX    RIXESSIOX  193 

actual  scUinf^f  back  of  ihc  muscle  toward  which  ihc  eye  <le\iates, 
viz.,  that  in  which  the  muscle  is  abnormally  short.  This  is  found  in 
certain  instances  of  congenital  squint,  and,  exceptionally,  in  the  case 
of  middle-aged  or  elderly  subjects  with  accjuired  squint  in  whom  the 
defect  has  been  of  many  years'  duration.  I  refer  {particularly  to 
those  in  which  the  length  of  the  muscle  is  so  inadequate  that  not 
only  is  the  eye  incapable  of  voluntary  rotation  in  the  opposite 
direction,  but  also  refuses  to  so  turn  under  fixation  forceps,  even 
with  the  subject  in  complete  narcosis.  The  condition  is  exceedingly 
rare,  the  writer  having  encountered  it  not  to  exceed  six  or  eight 
times  in  as  many  hundreds  of  operated  cases.  To  attempt  advance- 
ment of  the  antagonist  without  a  recession  of  this  short  muscle  would 
result  in  the  production  of  an  unwarrantable  degree  of  enophthalmos, 
and  still  greater  limitation  in  the  motility  of  the  globe.  Indeed, 
advancement  of  the  opposite  muscle  is  not  needful  save  in  a  certain 
percentage  of  these  cases,  the  recession  alone  being  sufficient.  The 
ordinary  complete  tenotomy  is  not  applicable  because  of  the  un- 
certainty as  to  w^hat  would  ultimately  become  of  the  severed  muscle. 
What  is  wanted  is  something  that  will  limit  the  extent  to  which 
the  cut  muscle  will  recede.  This  is  found  in  a  suture  arranged 
after  a  given  fashion.  The  first,  to  my  knowledge,  to  use  such  a 
suture,  was  A.  E.  Prince,  of  Springfield,  111.,  back  in  the  early 
"eighties."  I  have  not  at  hand  this  article  on  the  subject  nor 
do  I  recall  the  exact  technic.  Prince  called  it  "tenotomy  with  a 
control  suture."  A  httle  later,  Colburn,  of  Chicago,  made  a  similar 
tenotomy  and  named  the  thread  "  restrain  suture."  In  the  A  mcrican 
Journal  of  Ophthalmology  for  March,  1889,  the  writer  published  his 
method  of  making  the  operation  under  the  caption  "curl)  tenotomy." 
It  is  substantially  as  follows:  The  tendon  is  exposed  by  a  horizontal 
incision  through  conjuncti\a  and  capsule,  whose  center  is  over  the 
middle  of  the  insertion.  The  tendon  is  caught  upon  a  small  llattish 
hook,  which  is  shoved  back  to  free  the  muscle  from  its  sheath. 
A  double-armed  thread  of  No.  i  braided  silk  is  put  into  the  tendon 
2  or  3  mm.  behind  the  insertion  by  passing  a  needle  down  through 
close  to  each  border,  and  the  loop  thus  formed  pulled  down  snug. 
The  needles  are  then  carried  beneath  Tenon's  capsule,  one  above, 
the  other  1)elow,  just  in  line  with  the  loop,  given  a  good  bite,  and 
brought  out  through  both  capsule  and  conjunctiva.  While  the 
operator  holds  the  thread,  an  aid  rotates  the  eye  far  outward  (it 
being  the  internus)  in  order  to  still  further  loosen  the  tendon  from 


194  OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 

its  surroundings;  the  globe  is  set  free  and  the  suture  so  tied  as  to 
leave  a  slight  convergence.  The  same  suture  closed  the  opening  in 
the  membranes.  Of  course,  the  tendon  does  not  reunite  to  the  globe, 
but  to  its  aponeurosis.  In  about  half  my  cases  all  the  gain  was 
cosmetic;  the  rest  showed  increased  motihty  in  both  lateral 
directions. 

6.  Operations  Upon  the  Check  Ligaments. — Ailerons  Capsid- 
aires,  of  the  French,  and  Bindenfiiigels  of  the  Germans.  The  studies 
of  Motais,  Kalt,  and  others  have  demonstrated  that  it  is  possible  to 
enhance  the  power  of  an  ocular  muscle  by  judicious  division  of 
the  adjacent  check  ligament,  just  as  Landolt  has  shown  that  proper 
advancement  of  a  lateral  muscle  may  cause  extension  of  the  tield 
of  fixation  in  both  directions.  As  a  result  of  his  researches  Motais 
has  given  certain  rules  for  such  capsulotomy.  Supposing  an 
internal  squint:  Turn  the  eye  outward,  incise  conjunctiva  and 
the  tissue  beneath  it  from  near  the  cornea  to  the  center  of  the  tendon, 
thence  the  mucosa  along  its  whole  length  in  front  of  the  muscle. 
Now  feel  along  the  outer  surface  of  the  capsule  with  closed,  blunt 
scissors,  and,  back  some  9  or  10  mm.  (15  mm.  if  it  were  on  the  outer 
side)  the  instrument  encounters  a  pretty  firm  resistance.  This  is 
the  ligamentous  expansion  of  the  capsule.  The  scissors  are  opened, 
and  this  tissue  is  cut  with  short  snips  of  the  scissors. 

The  same  writer  also  gives  instructions  how  to  proceed  in  case 
the  ligament  is  to  be  cut  in  the  middle  of  its  course  or  at  its  union 
with  the  periosteum  of  the  orbit.  At  the  same  time,  he  strongly 
cautions  against  attempts  at  these  operations  by  those  who  are  not 
thoroughly  versed  in  the  anatomy  of  the  parts.  He  might  also  have 
added  that,  like  the  single  operation  of  strabotomy,  the  final  result 
is  problematical.  Moreover,  the  danger  of  orbital  cellulitis  must  be 
ever  present. 

Parinaud^  also  gives  a  method  for  setting  back  the  check  ligament. 
Given  a  convergent  squint,  the  eye  is  put  in  extreme  abduction  by 
forceps.  A  horizontal  fold  of  conjunctiva  is  picked  up  over  the  in- 
sertion and  cut  athwart  with  the  scissors  so  as  to  make  a  vertical 
incision  10  or  15  mm.  long,  and  at  the  distance  of  about  7  mm.  from 
the  cornea.  The  conjunctiva  is  undermined  back  to  the  caruncle, 
the  sheath  of  the  tendon  is  exposed  and  the  capsule  cut  along  its 
upper  borders.  Through  the  opening  thus  made  blunt  scissors  are 
thrust  and  the  fascia  is  cut  upward,  curving  a  little  backward,  for 

'  Note  ii  I'acadamie  des  sc,  14  avril,   1890. 


TENDON    LENGTHENING  195 

a  distance  of  lo  mm.  The  same  is  done  below  the  muscle.  The 
conjunctival  wound  is  closed  by  suturing.  A  capsular  advancement 
on  the  other  side,  and  even  tenotomy  on  the  same  side,  may  ac- 
company the  procedure. 

In  another  place  Parinaud^  recommends  setting  back  the  cajjsulc 
in  every  case  of  convergent  squint  when  spontaneous  lessening  of 
the  deviation,  once  begun,  had  ceased  to  progress;  especially  in 
those  where  the  wearing  of  glasses  had  caused  the  defect  only 
partially  to  disappear. 

7.  Tendon  Lengthening. — Sidney  Stephenson,  of  London 
according  to  an  article  in  the  Lancet  of  September  23,  1905,  was  the 
originator  of  this  class  of  squint  operations.  Realizing  the  ex- 
tremely uncertain  effect  of  simple  tenotomy,  it  occurred  to  him 
that  a  more  strictly  scientific  proceeding  would  be  to  lengthen  the 
tendon  of  the  rectus  muscle  without  at  the  same  time  interfering 
with  its  actual  insertion  into  the  sclerotic  coat  of  the  eyeball.     In 


Fig  90.  Fig.  91. 

this  way  he  hoped  that  the  dosage  of  tenotomy  might  be  rendered 
more  or  less  certain  instead  of  being,  as  in  the  old  operation,  an  al- 
most unknown  factor.  He  described  the  method  of  operating  and 
exhibited  several  patients  upon  whom  the  operation  had  been  per- 
formed, at  the  Ophthalmological  Society  of  the  United  Kingdom  in 
1902.  Briefly,  the  ste])s  of  the  operation  arc  as  follows:  A  vertical 
or  curvilinear  incision  is  made  with  scissors  over  the  insertion  of  the 
internal  rectus  muscle  and  the  latter  is  exposed  as  fully  as  might  be 
and  carefully  separated  from  the  overlying  conjunctiva  by  a  few- 
snips  of  the  scissors.  After  a  small  squint-hook  has  been  passed 
beneath  the  tendon  a  fine,  well-boiled,  silk  suture  is  inserted  through 
the  lower  border  of  the  tendon  close  to  the  sclera.  The  lengthening 
of  the  tendon  might  be  effected  in  several  ways,  of  which  the  two 
most  practical  alone  need  be  described:  i.  (Fig.  90.)  A  long  ob- 
lique incision  is  made  with  scissors,  commencing  at  the  lower  border, 
1  Bull,  et  mem.  de  la  soc.  franc,  d'opht.,  p.  291,  1893. 


196  OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 

near  the  scleral  insertion,  and  terminating  at  the  ui)])er  border  of  the 
muscle  some  distance  from  its  tendinous  attachment  to  the  eyeball. 
The  two  ends  of  the  tendon  are  then  united  by  a  couple  of  points  of 
interrupted  suture.  2.  (Fig.  91.)  The  lower  half  of  the  tendon  is 
cut  through  some  little  distance  from  the  scleral  insertion  and  the 
incision  is  carried  along  the  center  of  the  tendon,  midway  between 
its  u])per  and  lower  border,  finally  to  be  brought  out  at  a  right  angle 
lo  its  former  course.  The  free  ends  left  by  this  step-like  incision 
are  united  by  sutures.  The  lengthening  of  the  tendon  as  carried  out 
by  cither  of  the  foregoing  methods  should  be  directly  proportionate 
to  the  linear  measurement  of  the  squint;  in  other  words,  in  a  strabis- 
mus of  five  millimeters  an  attempt  to  lengthen  the  tendon  by  just 
that  amount  should  be  made.  The  final  step,  after  the  tendon 
sutures  have  been  tied  and  cut  off  short,  is  to  close  the  conjunctival 
incision  neatly  with  several  points  of  interrupted  suture.  The 
operation  of  tendon  lengthening  may  or  may  not  be  combined 
with  tenectomy  and  advancement  of  the  antagonist  muscle. 
Stephenson  remarks,  in  passing,  that  an  agent  has  recently  been 
placed  at  our  disposal  that  acts  even  better  in  inducing  local  an- 
esthesia and  hemostasis  in  those  cases  than  cocain  and  adrenalin 
applied  separately  to  the  eye.  The  new  combination  has  received 
the  name  of  "cusemin"  and  consists  of  cocain,  adrenalin,  and  chlore- 
tone  dissolved  in  physiologic  salt  solution.  Applied  to  the  eye 
before  and  during  the  performance  of  the  operation,  eusemin 
renders  the  work  at  once  simpler  and  more  speedy.  He  further 
says  that  the  operation  of  muscle  lengthening  is  by  no  means  easy 
to  do,  but  he  is  convinced  that  it  is  more  exact  and  scientific  than 
the  ordinary  tenotomy,  and  the  results  can  be  foreseen  and  graded 
with  considerable  accuracy. 

The  technical  difficulties  of  tendon  lengthening  led  tlie  writer  to 
find  a  simpler  substitute  and  he  made  use  of  a  device  adopted  by 
orthopedic  surgeons — viz.,  the  so-called  "artificial  tendon."  This 
procedure  is  explained,  and  as  applied  to  the  internal  rectus  muscle 
is  described  as  follows: 

"The  tendon  is  exposed  as  in  the  former  case  and  two  sterilized 
silk  threads  are  passed  through  the  tendon  about  three  millimeters 
from  its  scleral  insertion — one  through  llie  ui)pcr  and  llie  other 
through  the  lower  border  of  (lie  muscle.  The  threads  are  then 
knotted,  one  long  end  armed  with  a  small  curved  needle  being  left 
attached  to  each.     'J'he  tendon,  lluis  securelv  lield,  is  next  divided 


VERHOEFF  S    METHOD  1 97 

vertically  on  the  outer  side  of  the  knot — that  is  to  say,  about  midway 
between  the  latter  and  scleral  insertion  of  the  tendon.  The  threaded 
needles  are  then  passed  between  the  distal  and  the  proximal  portions 
of  the  divided  tendon  in  such  a  way  as  to  bridge  over  the  gaj)  left 
between  the  Iwo.  I^astly.  the  two  sutures  are  tied  together.  An 
even  simpler  way  of  forming  the  artiikial  tendon  is  to  use  two 
needles  on  one  length  of  silk.  Jf  advancement  of  the  antagonist 
muscle  has  formed  part  of  the  operation,  the  sutures  should  not  be 
adjusted  until  the  first  operation  has  been  completed.  ]i,  on  the 
contrary,  muscular  elongation  is  alone  contemplated,  then  before 
the  threads  are  tied  the  eyeball  should  be  strongly  abducted  so  as  to 
leave  a  distinct  interval  before  inserting  the  silk  threads  of  the  artifi- 
cial tendon." 

Landolt^  has  recently  proposed  a  method  of  muscle  elongation. 
He  designed  it  for  those  inveterate  cases  of  convergent  sfjuint 
in  which  there  is  marked  contraction  of  the  internal  rectus,  accom- 
panied by  changes  in  its  structure  and  the  loss  of  elasticity.  The 
tendon  is  laid  bare  by  a  horizontal  incision  over  the  center, 
and  stretched  flat  upon  a  strabismus  hook.  \\'hile  an  assistant 
rotates  the  globe  outward  the  rectangle  represented  by  the  tendon  is 
bisected  diagonally.  The  apex  of  one  of  the  right- angle  triangles 
thus  formed  is  united  by  suturing  to  that  of  the  other.  Another 
way  mentioned  is  to  divide  the  tendon  by  a  series  of  cuts  in  the  form 
of  steps,  and  joining  the  last  step  on  one  side  to  the  corresponding 
one  on  the  other.  By  a  curious  coincidence,  Landolt  has  hit  upon 
precisely  the  same  idea  as  did  Stephenson.  In  this  connection 
the  following  question  suggests  itself,  viz.,  may  not  the  result  of 
such  operations,  in  cases  where  the  eyes  are  capable  of  binocular 
single  vision,  be  a  serious  disturbance  of  the  muscle  balance,  owing 
to  the  peculiar  manner  in  which  the  ends  of  tendon  are  united  ? 

Verhoeff2  has  suggested  a  form  of  tendon  lengthening  which  is 

presumed  to  find  its  application  only     ^_^  

in  the  lowest  degrees  of  strabismus.  |  r^^ 

It  consists  in  laying  bare  the  tendon 

of  the  muscle  toward  which  the  globe 

is  deflected,   buttonholing  it   in  the  vertical  sense  and,  in  addition, 

making  a  series  of  nicks  in  its  edges.     It  is  through  stretching  out 

of  the  tendon  consequent  upon  the  oj)ening  of  these  cuts  that  the 

1  Archiv.  d'Ophtal.,  January,  1905. 
2Mbl.  F.  A.,  Band  xli,  1903.' 


198  OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 

effect  is  obtained.  Figs.  92  and  93  show  the  cuts  closed  and  open. 
This  is  nothing  else  than  a  form  of  partial  tenotomy,  and  Haab  ^ 
significantly  observes,  in  referring  to  the  measure,  "Ob  diese  Oper- 
ation bleibendere  Resultatc  erzielt  als  die  partiellen  Tenotomien, 
welche  friiher  schon  von  verschiedenen  xAutoren  vorgcschlagen  und 
ausgefiihrt  wurden,  muss  die  Erfahrung  lehren." 

While,  as  before  stated,  some  degree  of  vertical  deviation  is 
common  in  connection  with  horizontal  squint,  operations  upon 
the  muscles  that  rotate  the  eye  upward  or  downward  are  seldom 
indicated.  Correction  of  the  lateral  deviation  usually  corrects  the 
vertical  also.  At  all  events,  and  generally  speaking,  no  attention 
need  be  given  to  any  hypo-  or  hypertropia  until  there  is  full  redressal 
of  the  eso-  or  exotropia.  Then,  if  a  vertical  squint  persists,  it  is 
time  for  its  surgical  treatment.  Its  cause  may  be  looked  for  either  in 
one  of  the  vertical  recti  or  in  one  of  the  obliques.  The  vertical  recti 
in  such  cases  lend  themselves  readily  to  the  same  operative  measures 
as  do  the  other  two  straight  muscles.  The  obliques  do  not.  Indeed 
these  are  hardly  amenable  to  surgical  interference  of  any  kind. 
The  inferior  may  be  tenotomized,  and  the  writer  has  twice  performed 
the  operation,  and  with  gratifying  results;  but  the  undertaking  is 
both  laborious  and  risky. 

From  time  to  time  more  or  less  complete  tenotomies  of  the  superior 
and  the  inferior  rectus  muscles  have  been  advised  for  the  cure — or 
as  aids  to  the  cure — of  horizontal  squint.  Stevens,  of  New  York, 
for  a  time,  seemed  truly  ardent  in  his  advocacy  of  such  measures. 
Ever  since  the  early  investigations  of  Landolt,  in  regard  to  the 
ocular  movements,  it  has  been  known  that  the  vertically  acting 
recti  were,  in  addition,  by  their  dual  contraction,  decided  adductors 
of  the  globe — thus  being  the  normal  antagonists  of  the  combined 
obliques.  Landolt  also  pointed  out  that  normally  directed  eyes 
are,  relative  to  the  long  axes  of  the  recti  muscles,  already  in  a  stale 
of  convergence.  Moreover,  that,  under  certain  abnormal  concHtions, 
the  vertical  recti  could  become  abductors.  (ji\en,  for  instance, 
narrow  central  insertions  of  their  tendons,  especially  if  the  globe  be 
of  large  size,  as  in  certain  myopes,  and  the  lateral  muscles  are  lack- 
ing in  tone,  and  we  liave  whal  the  writer  once  dcscril)cd  as  pivolal 
allaclinieiil.  where  there  was  c()n\ergenl  squint  in  near  \isi(,)n  and 
divergent  for  distance.  Here  the  muscles  and  their  insertions  l)ore 
the  same  relations  to  the  globe  that  two  shafts  with  their  pivots, 

'"  Au.ncn-operationslehre,"  ]>.  278,1894. 


Jackson's  displacement  199 

or  cranks,  would  bear  to  a  wheel.  The  moment  the  rotation,  in 
either  direction,  carried  the  pivot-like  attachment  beyond  the  center 
of  motion  the  deviation  became  markedly  manifest. 

Quite  recently,  Jackson, ^  of  Denver,  in  a  paper  entitled  "Lateral 
Displacement  of  Tendon  Insertions  for  the  Cure  of  Strabismus," 
recommends  tenotomy  of  the  inner  half,  to  three-fourths,  of  the 
tendons  of  the  superior  and  inferior  recti,  or  even  complete  tenotomies 
of  them,  and  their  reattachment  to  the  sclera  in  a  more  favorable 
manner,  by  suturing.  He  has  practised  lateral  displacement  by 
partial  tenotomy  on  the  superior  and  inferior  recti  muscle  chiefly 
for  the  correction  of  excess  of  convergence,  and  describes  his  method 
of  operating.  He  claims  this  operation  is  followed  by  no  diplopia 
and  by  no  more  reaction  than  ordinary  complete  tenotomy.  Jackson 
considers  lateral  displacement  of  the  tendon  insertions  of  the  superior 
and  inferior  recti,  in  connection  with  tenotomy  of  the  internus,  as 
an  effective  and  reliable  operation  for  high  degrees  of  convergent 
squint.  He  begins  with  a  complete  tenotomy  of  the  internus, 
and  through  the  same  conjunctival  opening  the  scissors  are  intro- 
duced and  the  nasal  one-half  to  three-fourths  of  the  tendon  of  the 
superior  or  inferior  rectus  is  divided  at  its  insertion.  He  strips 
the  edge  of  the  tendon  back  one-half  inch  or  more  from  the  insertion 
by  means  of  a  strabismus  hook.  He  cites  a  case  where  this  opera- 
tion was  performed  successfully  for  a  high  degree  of  squint,  and 
explains  that  no  protrusion  of  the  eyeball  or  other  bad  result  has 
been  observed. 

There  are,  now  and  then,  instances  wherein,  after  careful  study 
of  the  muscular  anomalies  that  are  present,  one  is  convinced  that 
there  is  undue  tension  upon  one  edge  of  a  broad  tendon,  and  that  un- 
questionably, a  well-directed  partial  tenotomy  is  indicated.  But 
to  make  anything  like  regular  practice  of  this  kind  of  strabotomy 
is  to  enter  upon  delicate  ground  and  to  invite  indiscriminate 
intervention  in  the  matter  on  the  part  of  muscle-snippers.  As 
said  before,  it  is  my  belief  that  it  is  only  exceptionally  that  one  need 
consider  the  vertical  muscles  as  factors  in  a  squint,  at  least  to  the 
extent  of  attacking  them  surgically.  And  often  even  when  they 
seem  to  be  directly  responsible  for  the  defect,  they  are  only  indirectly 
so,  i.e.,  merely  because  of  a  lack  of  balance  or  a  want  of  dynamic 
adjustment  on  the  part  of  the  other  two  recti.  In  the  ])iv{)lal 
attachment,  just  alluded  to,  had  the  internus  and  llie  externus  been 

ijournal  of  the  Am.  Med.  Assn.,  Aug.  19,  1905. 


200        OPERATIONS  UPON  THE  EXTERNAL  MUSCLES 

properly  in  rein,  so  to  speak — rightly  toned — there  would  probably 
have  been  no  squint  in  either  direction. 

Advancement  for  Secondary  Squint. — A  goodly  percentage 
of  the  s(]uints  with  which  one  has  to  deal  are  of  this  variety,  and, 
while  the  surgical  measures  appropriate  to  some  of  them  might 
come  under  the  head  of  a  form  of  advancement,  others  constitute 
a  class  by  themselves,  and  the  surgeon  must  resort  to  special  methods 
to  meet  the  demands  of  the  individual  case.  This  class  is  charac- 
terized not  only  by  exaggeration  of  the  exophthalmos,  retraction 
of  the  caruncle,  etc.,  but  by  that  of  extent  of  adhesions  and  scar 
tissue  as  well.  If  one  fears  that  it  will  be  difficult  to  obtain  a  firm 
forward  anchorage  for  his  suture  he  would  better  weaken  the  opposing 
tendon  by  a  large  transverse  buttonhole.  Then  comes  the  task 
of  procuring  the  needed  raw  surface  near  the  cornea  with  which  the 
tissue  to  be  advanced  is  to  unite.  In  the  worst  cases  this  can  be 
obtained  only  by  a  laborious  dissection.  This  can  best  be  accom- 
plished by  the  use  of  very  small  mouse-toothed  forceps  and  scissors, 
beginning  well  back  where  the  tissue  is  looser,  and  trying  to  open  up 
a  wide  path  toward  the  cornea  in  the  horizontal  meridian.  If 
one  encounters  an  island  of  scar  so  firmly  incorporated  with  the 
sclera  that  it  cannot  be  separated,  it  may  be  freshened  with  a  small, 
very  sharp,  finely  serrated  curet.  Now  the  muscle,  or  the  remains 
of  it,  must  be  searched  for.  If  nothing  having  the  semblance  of 
a  tendon  and  aponeurosis  can  be  found — if  all  is  united  in  one  mass 
with  the  conjunctiva — a  sort  of  pyramidal  flap,  with  its  apex 
toward  the  cornea  is  formed  by  diverging  incisions  of  the  united 
membranes,  putting  the  regulation  advancement  suture  or  sutures 
in  near  the  apex,  bringing  the  whole  flap  forward  and  securing  it 
just  as  one  would  a  tendon.  In  this  way  the  deformities,  at  least, 
(and  usually  at  most)  can  be  corrected.  Yet  it  is  remarkable 
how  much  control  is  sometimes  obtained  by  the  reinstated  muscle 
over  the  movement  of  the  globe. 

Accidents  and  other  sequels  conscfpient  upon  advancement 
are,  in  many  res])ects,  identical  with  those  atten(hng  tenotomy 
already  gi\en.  Care  must  Ije  exercised  to  i)revent  operating  on 
the  wrong  eye,  cutting  or  breaking  the  thread,  etc.  The  thread 
should  be  braided,  not  twisted,  and  ought  to  be  previously  examined 
as  to  strength  and  c\enness,  as  well  as  to  see  that  there  are  no  little 
breaks  in  lis  strands,  'i'hc  use  of  so-called  self-threading  needles 
is  prejudicial  since  llicy  arc  apt  lo  cul  and  make  weak  places.     The 


CHOICE    OF    METHOD  201 

cutting  out  of  the  sutures  can  best  be  avoided  by  usin.t^^  thread  of 
only  medium  fineness  and  by  giN  ing  it  the  ])r()|)rr  hold  in  the  tissues. 
Manifestly  one  cannot  de])end  ui)on  tiie  numberin.t^^  printed  or 
written  U])on  the  spools  or  skeins  of  thread  by  the  manufacturers; 
what  is  No.  i  in  one  make  is  No.  2  or  No.  3  in  another,  and  so  on. 
Thread  that  has  been  treated  witli  a  pre])aration  of  wax  or  ])ararfin 
is  vastly  preferable  for  se\eral  reasons.  It  does  not  snarl,  it  does 
not  make  a  track  for  bacteria,  and,  being  nonabsorbent,  is  easier 
drawn  through  the  tissues.  It  holds  better  because  bacteria  do  not 
proliferate  around  it  and  soften  the  ])arts.  If,  at  the  first  dressing,  it 
is  discovered  that  the  thread  has  escaped  from  some  part  of  its 
fastenings,  the  fault  may,  in  some  instances,  be  remedied  by  the 
judicious  placing  of  a  single  new  thread  in  such  away  as  to  counteract 
it.  If  merely  too  much  dropping  back  of  the  tendon  has  occurred, 
without  cutting  out  of  the  suture,  I  have  been  able,  at  times,  in  the 
one  suture  method,  to  pull  the  thread  up  tight  again,  twist  it  into 
a  pedicle,  and  ligate  it.  Of  course,  if  the  thread  is  left  in  a  bow  knot 
at  the  time  of  the  operation,  the  matter  is  simple  enough. 

Advancing  capsule  and  conjunctiva  with  the  tendon.  If  this 
be  done  in  too  comprehensive  a  manner,  it  leads  to  restriction  of 
motility  by  tightening  the  check  ligament  in  the  one  instance,  and 
to  advancement  of  the  caruncle  and  obliteration  of  the  semilunar 
told  in  the  other. 

Wounding  and  bruising  of  tlie  parts  should  not  only  occur  in 
the  minimum  degree,  but  should  be  kept  as  well  forward  as  practi- 
cable so  as  not  to  interfere  with  what  Landolt  calls  the  normal  unrolling 
of  the  operated  muscle  upon  the  globe;  in  other  words,  the  true 
advancement  effect  is  nullified  in  proportion  as  the  adhesions  reach 
backward. 

Enophthalmos  after  advancement  operations  has  been  referred 
to  as  an  objectionable  feature.  It  is  usually  insignificant,  yet  it 
affords  an  additional  argument  for  operating  upon  both  eyes  in  the 
higher  degrees  of  squint  in  order  to  prevent  an  apparent  difference 
in  the  width  of  the  pal])e1)ral  fissures. 

GENERAL  CONSIDERATIONS  ON  ADVANCEMENT. 

Age  of  Subject. — A  s(|uint  operation  would  not,  as  a  rule,  be 
justifiable  prior  to  the  age  when  it  could  be  ascertained  whether 
or  not  other  than  surgical  measures  could  avail.     There  are  ex- 


202  OPERATIONS    UPON    THE    EXTERNAL    MUSCLES 

ceptions,  however,  to  this  rule,  as,  for  example,  cases  of  congenital 
strabismus  with  unnatural  shortness  of  the  muscle  or  muscles. 
If  this  were  suspected,  it  could  be  differentiated  from  spasmodic 
squint  by  placing  the  patient  under  ethyl  chlorid,  nitrous  oxid,  or 
similar  anesthetic,  and  testing  the  rotation  of  the  eye  with  forceps. 
Then,  too,  there  is  that  class  where,  without  any  brevity  of  muscle 
in  the  direction  of  the  deviation,  motility  in  the  opposite  direction  is 
so  very  limited,  and  the  degree  of  deflection  is  so  high,  that  it  is  a 
foregone  conclusion,  particularly  if  the  patient  belongs  to  the  lower 
and  irresponsible  station  of  life,  that  it  is  merely  a  question  as  to 
whether  one  operates  at  once  or  leaves  a  permanent  squint. 

Choice  of  Method. — Where  there  are  so  many  effective  modes, 
this  would  seem  to  be  largely  a  matter  of  individual  preference. 
If  one  has  happened  upon  or  selected  a  method  with  which  he  has 
become  familiar,  and  been  uniformly  pleased,  he  is  not  apt  to 
exchange  it  for  another.  There  are  a  few  squint  operations  for 
which  their  authors  do  not  claim  universal  application,  yet  any 
measure  that  is  capable  of  causing  25  to  30  degrees  of  redressment 
of  a  squint  is  suflfiicient  for  all  cases,  provided  both  eyes  are  operated 
upon.  There  are  relatively  few  instances  wherein  the  deviation 
exceeds  50  degrees,  and  if  it  is  better,  as  is  pretty  well  agreed,  since 
the  affection  in  question  is  a  binocular  one,  that  the  corresponding 
muscle  of  both  eyes  be  operated,  then  the  need  of  bilateral  interfer- 
ence is  all  the  more  urgent.  In  practice,  however,  we  cannot 
always  count  upon  an  opportunity  of  making  a  second  operation, 
but  may  often  wish  to  make  a  single  sitting  suffice.  If  one  has 
scruples  against  tenotomy  as  a  means  of  curing  squint,  he  would, 
then,  prefer  an  operation  that,  all  things  else  being  equal,  would 
give  the  maximum  of  effect.  But  are  all  things  else  equal  ?  The 
maximum  of  effect  could  doubtless  be  obtained  by  most  any  of  the 
shortening  processes,  either  folding  or  resection,  but  would  the 
result  be  in  every  way  as  good  as  after  a  true  advancement  ?  The 
advocates  of  the  latter  would  say,  "No!"  They  believe  that  to  give 
the  muscle  the  greatest  power  or  leverage  over  the  globe,  it  should  be 
given  an  attachment  forward  of  its  original  one,  and  it  is  in  this  that 
a  veritable  advancement  mainly  consists;  that,  while  there  are  most 
excellent  measures  among  the  shortening  operations,  their  sphere  is 
limited  to  the  lower  degrees  of  squint.  Admitting  that  they  who 
prefer  ad\an(H'mc'nt  are  right,  what  kind  of  an  acl\ancenicnt  can 
be  reckoned    upon   lo   gi\c    the   greatest   and    best   effect?      For  it 


CHOICE    OF    MKTIIOD 


203 


must  be  remembered  that  permanent  over-efTects,  or  secondary 
squints,  do  not  occur  after  advancement  operations  except  where 
too  much  tenotomy  has  accompanied  the  operation.  Two  h'ttle 
effect,  even  after  both  eyes  ha\e  been  operated,  is  frequent. 
Moreover,  to  get  very  decided  permanent  effect  one  must  strive 
for  yet  more  decided  primary  effect,  i.e.,  over-effect;  for  some 
dropping  back  of  the  tendon  is  inevitable.  As  to  the  degree 
of  primary  effect,  one  must 
be  guided  by  his  judgment 
—knowing,  as  he  ought, 
the  angle  of  the  squint 
and  other  peculiarilies  of 
the  case  in  hand.  In 
divergent  and  paralytic 
squint,  it  goes  without  say- 
ing that  the  over-eft'ect 
must  be  specially  pro- 
nounced. The  forms  of 
advancement  thai  will  give 
the  maximum  turning  of  the 
globe  with  the  minimum 
resection  or  obliteration  of 
tendon  are  those  whose  sutures  begin  to  take  their  proximal  anchorage 
beyond  the  nearer  vertical  tangent  of  the  cornea  (Fig.  94). 

The  anchorage  must  be  beyond  the  tangent;  it  will  not  do  to  be 
merely  even  with  it.  This  is  not  to  imply  that  those  methods  wherein 
said  anchorage  is  between  the  cornea  and  the  operated  muscle 
are  necessarily  inferior.  *  Doubtless  there  are  good  measures  and 
bad  ones  in  both  classes.  Given  an  equally  good  one  on  either  side, 
it  becomes  simply  a  question  as  to  whether  or  not  one  wishes  to  in- 
crease the  turning  of  the  globe  at  the  expense  of  the  tendon.  Given 
two  equally  good  measures  in  either  class,  it  becomes  largely  a 
question  as  to  which  is  simpler.  From  reading  the  descriptions  one 
would  conclude  that  there  are  needlessly  complicated  procedures  in  all 
the  classes,  but  descriptions  are  apt  to  be  misleading  in  this  respect. 

Most  all  the  single  suture  advancement  operations  have  the 
merit  of  drawing  the  muscle  straight  forward.  This  is  not  true, 
however,  of  those  wherein  the  thread  is  knotted  in  or  tied  to  the 
tendon.  It  can  be  done  with  the  multiple  suture  methods  that  have 
a  meridional  thread,  by  tying  this  first,  but  this,  again,  is  in  the  way 


Fig.  94. — Anchorage  obtained  in  the  spaces 
a  and  b,  i.e.,  on  the  corneal  side  of  the  nearer 
vertical  tangent  of  the  limbus,  affords  a  more 
positive  advancement  than  one  obtained  in  the 
space  c. 


204  OPERATIONS    UPON   THE    EXTERNAL   MUSCLES 

of  a  full  effect.  A  certain  vertical  detlection  of  the  muscle  is  difficult 
to  avoid  in  the  two  suture  modes.  Another  advantage  of  the  single 
suture  is  that  it  facilitates  removal.  One  has  merely  to  grasp  the 
knot  with  the  forceps  and  cut  the  suture.  If  the  knot  is  not  held 
by  the  forceps  one  risks  attempting  to  pull  it  through  the  stitch 
canal.  It  is  a  curious  fact  that  there  is  more  dread  and  flinching  on 
the  part  of  the  average  patient  relative  to  the  taking  out  of  the  thread 
than  to  the  making  of  the  operation  itself.  •  This  is  a  strong  argument 
in  favor  of  the  catgut  suture  referred  to. 

A  great  deal  has  been  said  about  the  advantage  of  this  or  that 
advancement  procedure  in  that  the  arrangement  of  the  suture  or 
sutures  in  the  tendon  tends  to  prevent  its  cutting  out.  From  an 
abundant  experience  with  his  own  method,  both  as  performer  and 
onlooker,  the  writer  has  long  since  come  to  the  conclusion  that  it  is 
far  easier  for  the  average  surgeon  to  obtain  a  firm  hold  for  the 
thread  in  capsule  and  tendon  than  in  the  globe;  and  this  with  regard 
to  an  operation  where  the  suture  is  not  tied  fast  to  the  tendon  by 
"surgeon's  knots."  It  may  be  that  more  is  lost  than  gained  by 
these  ligations  of  the  tendon. 

The  object  of  the  accompanying  tenotomy  being  only  for  its 
temporary  effect,  the  writer  often  omits  it  in  the  lower  degrees  of 
squint,  but,  owing  to  the  fact  that  the  greater  the  rotation  the  greater 
the  resistance  of  an  unweakened  opponent,  tenotomy  has  come  to  be 
an  auxiliary  in  all  whose  angle  is  above  25  degrees.  If  advance- 
ment of  the  corresponding  muscle  of  each  eye  fails  to  correct  the 
squint,  rather  than  make  a  tenotomy  to  complete  the  cure,  a  second 
advancement  is  made  in  case  of  the  first  eye  operated.  I  consider 
advancement  preferable  to  tenotomy  for  every  form  of  squint,  latent 
or  manifest,  where  surgical  measures  are  at  all  indicated. 

Orthoptic  and  fusion  training  are  instituted  at  the  earliest 
moment  after  operating  in  order  to  enhance  the  result.  Binocular 
single  vision,  however,  is  not  the  rule  in  these  cases.  But,  as 
Landolt  has  pointedly  said,  the  best  that  the  most  skilled  can  do  is 
to  put  the  eyes  approximately  right  and  rely  upon  Nature  to  do  the 
rest.     So,  by  these  exercises  we  strive  still  further  to  assist  Nature. 

The  length  of  time  one  should  wait  before  making  a  similar 
oj^eration  on  the  fellow  eye  must  be  regulated  by  circumstances. 
In  children,  and  all  those  where  there  is  hope  of  gaining  the  end  by 
the  help  of  other  means,  from  six  months  to  a  year  is  not  too  long. 


GENERAL    CONSIDERATIOXS  205 

As  regards  older  subjects,  and  those  with  hi,L,di  and  incorrigible 
amblyopia,  it  is  useless  to  wait  longer  than  a  month  or  so. 

Anesthesia. — Wherever  feasible  one  should  make  the  oj)eration 
under  local  anesthesia,  and  it  is  the  writer's  custom  even  in  case  of 
small  children — from  7  to  12  years  of  age — although  they  are  pre- 
pared for  narcosis,  to  begin  under  cocain.  If  they  bear  it  uncom- 
plainingly, well  and  good;  if  not,  they  are  narcotized.  .V  pretty 
large  percentage  of  these  little  ones  can  be  ojjcrated  without  being 
put  to  sleep.  The  suggestion  of  Eales,^  of  making  the  tenotomy 
and  first  step  of  the  advancement  under  cocain,  and  then  giving 
ethyl  chlorid  or  some  such  anesthetic  for  the  sewing  seems  a 
plausible  one.  The  subconjunctival  injection  of  cocain  is  not  free 
from  danger,  and  makes  a  mess  of  the  tissues  concerned.  Three 
or  four  drops  of  a  4%  solution  made  from  a  good  quality  of  cocain 
produces  perfect  anesthesia  in  most  eyes,  though  it  is  well  to  put  a 
drop  or  two  into  the  wound  as  soon  as  the  conjunctiva  is  incised, 
both  for  the  tenotomy  and  for  the  advancement. 

As  to  safety,  advancement  ranks  about  as  high  as  any  operation 
that  is  made  on  the  eye.  In  all  my  experience  I  have  never  seen  but 
a  single  eye  that  gave  me  serious  alarm  thereafter.  This  was  a  dis- 
pensary patient  who  was  allowed  to  go  home  directly  from  the  operat- 
ing-room, but  with  instructions  to  report  on  the  second  day.  He 
did  not  return  till  the  end  of  the  fourth  day.  The  bandage  was 
filthy,  the  dressing  w-as  off  the  eye,  and  there  was  septic  tenonitis 
at  the  site  of  the  advancement,  with  a  deep  infiltration  in  the  nearest 
segment  of  the  cornea.  The  suture  w'as  at  once  removed,  the  man 
put  under  treatment  in  the  hospital,  and  the  eye  made  a  complete 
recovery. 

A  neat  and  effective  advancement,  though  safe  and  sim])le  as  to 
detail,  is  by  no  means  easy  of  execution,  the  great  dirficulty  lying 
in  the  deep  anchorage  required  for  the  sutures  in  the  globe.  The 
older  the  subject,  the  more  difficult  this  becomes.  To  pierce  the 
superficial  layers  of  the  sclera  for  the  requisite  distance  without 
going  through  and  in  such  a  way  that  the  tunnel  of  the  needle  will 
not  be  ripped  open  in  drawing  the  suture  through  is  the  key  to  the 
situation.  Fine  needles,  of  proper  shape  and  irreproachable  sharp- 
ness, together  with  steadying  the  globe  by  holding  with  fixation 
forceps  the  tendon  at  its  attachment,  go  a  long  way  toward  lessen- 
ing the  labor  of  this  step;  though  nothing  but  practice  will  give  the 

1  Brit.  Med.  Jour.,  Jan.,  18S8,  p.  349. 


2o6 


OPERATIONS  UPON  THE  EXTERNAL  MUSCLES 


necessary   skill.     This   can   be  attained  to  a   tolerable  degree  by 
operating  upon  pig's  eyes  in  a  mask. 

To  give  the  lines  of  anchorage  a  highly  divergent  direction  serves 
three  important  purposes:  i.  It  prevents  the  thread  in  its  back- 
ward course  to  the  loop  from  overlying  the  cornea.  2.  The  ad- 
vancement can  be  more  posi- 
tive, i.e.,  it  allows  the  tendon 
to  be  drawn  quite  up  to  the 
cornea.  3.  Any  dropping 
back  or  cutting  of  the  thread 
is  minimized  in  proportion 
to  the  degree  of  divergence, 
hence  magnified  in  propor- 
tion as  the  lines  of  anchorage 
approach  parallelism.  On 
the  other  hand,  the  solidity 
and  security  of  the  anchor- 
age is  increased  in  propor- 
tion as  its  lines  become  more 
nearly  horizontal,  for  the 
reason  that  the  strain  of  the 
thread  is  thus  distributed  along  the  sides  of  the  stitch  canal,  whereas, 
the  more  divergent  the  lines,  the  more  the  strain  is  concentrated  at 
the  distal  extremity  of  the  canal.  These  points  are  illustrated  by 
Fig.  95 ;  aa  indicate  the  further  ends  of  the  scleral  anchorage,  situated 
at  five  mm.  from  the  cornea  on  the  vertical  meridian.  This  insures 
a  maximum  advancement  without  contact  of  the  thread  with  the 
cornea.  Now,  in  order  to  give  greater  firmness  to  the  hold  of  the 
thread  in  the  sclera  it  is  not  inserted  along  the  lines  ca,  but  is  made 
to  follow  the  lines  ca.  Still  greater  lateral  strain  in  the  anchorage 
would  be  obtained  by  following  the  lines  c'a,  or  to  make  them 
actually  parallel,  but  this  would  add  greatly  to  the  difficulties  of  the 
operation.     It  would  also  shorten  the  anchorage. 


VM 


V.T. 


Fig.   95. — The    anchorage    cannot    be    long. 
Essential  that  distal  portion  should  be  deep. 


CIIAP'JKR   V. 
OrERATIONS  UPON  THE  LIDS. 

EVERSION. 

Eversion  of  the  lid  consists  in  turning  it  so  as  to  expose  its 
conjunctival  surface,  together  with  the  retrotarsal  folds,  and  to 
accomplish  which  the  essential  feature  implies  the  inverting  of  the 
stiffening  plate  of  the  lid,  viz.,  the  tarsus.  The  ends  sought  in 
everting  the  lids  are  manifold,  such  as  examination  and  topical 
treatment  of  the  conjunctiva,  the  removal  from  it  of  foreign  bodies, 
the  excision  of  tumors  of  the  tarsal  plates  and  the  making  of  various 
other  operations.  Although  the  performance  seems  a  simple  afifair, 
it  is  really  one  involving  considerable  sleight,  and  the  constant  need 
of  the  procedure  gives  it  importance.  Moreover,  the  fact  that  the 
eye,  naturally  a  sensitive  organ,  is  rendered  all  the  more  so  by  the 
affections  requiring  eversion,  makes  it  incumbent  on  the  operator 
to  be  deft  in  its  execution.  The  novice  is  hardly  expected  to  do  the 
thing  without  awkwardness,  but  that  so  many  of  the  older  and  more 
experienced  eye  surgeons  should  perpetually  exhibit  this  quality  in 
the  little  act  is  truly  surprising. 

Method  for  the  Upper  Lid,  (Fig.  6). — Standing  or  sitting  in 
front  of  the  subject,  the  operator  rests  the  tips  of  the  fingers  of  his 
right  hand  upon  the  brow;  with  the  thumb  and  index  of  the  left 
hand  he  takes  hold  of  the  lashes,  tells  the  patient  to  look  all  the  while 
far  downward  and  to  refrain  from  squeezing.  He  pulls  the  lid  well 
down  on  the  stretch  and  slightly  away  from  the  eyeball,  places  the 
right  thumb  on  the  skin  opposite  the  upper  border  of  the  tarsus, 
pressing  it  downward  and  backward  rather  slowly  and  steadily 
at  first,  till,  feeling  that  he  has  the  plate  well  in  hand,  he  gives  a 
quicker  down  and  back  impulse  to  the  upper  border  and  an  equally 
quick  forward  and  upward  one  to  the  free  border,  ending  the  move 
in  turning  the  tarsus  completely  upside  down  (Fig.  97).  The  right 
hand  is  removed  as  is  the  left  forefinger,  but  the  left  thumb  remains 
to  hold  the  lid  everted,  by  pressing  the  lashes  back  against  the 
globe  and  having  for  solid  support  the  rim  of  the  orbit  above 
(Fig.  98).     If,  as  is  sometimes  the  case,  the  lashes  are  wanting,  a 

207 


208 


()Pp:rati()xs  upon,  the  lids 


slilT  i)robc  or  similar  inslrumcnl  is  used  lo  press  the  convex  border 
of  the  tarsus  down  and  back,  till  the  free  border  pouts  very  de- 
cidedlv.  when  with  the  left  thumb  it   is  adroitly  shoved    up,  rolled 


lie.  ()6. — Method  of  everting;  lid.     1" 


back,  and  Iield,  possibly  with  the  probe  left  /;/  situ  to  help  (Fig.  99). 
This  instrumental  eversion  is  useful  also  where  the  patient  is  touchy 
or  the  orbicularis  is  spasmodic,  but  it  is  best,  as  a  rule,  to  rely  upon 
tlie  liriLH'rs  alone.      In  fad,  to  be  al)le  to  make  a  neat  eversion  with 


EPILATION 


209 


the  left  hand  unaided  by  the  right  is  a  most  convenient  acquire- 
ment, for  the  reason  that  it  is  so  often  desirable  to  have  an  instru- 
ment in  the  right,  all  ready  for  use.  To  do  it,  the  ofllce  performed 
by  the  left  thumb  and  index  is  precisely  as  described  for  the  two 
hands  and  in  lieu  of  llie  right  thumb,  the  upper  border  of  ihe  tarsus 
is  manipulated  by  the  left  middle  finger. 


Fig.  97- — Eversion  of  lid.     Stv ond  step. 


Epilation  of  the  margins  of  the  lids  is  advisable  as  regards 
any  hairs  that  are  in  the  way  of  proper  application  of  remedies,  as 
in  blepharitis  or  for  the  temporary  riddance  of  any  that  offend  by 
touching  the  cornea,  or  conjunctiva,  and  is  done  by  means  of  the 
cilia  forceps  (Plate  V). 

The  chief  requirements  of  this  instrument  concern  the  jaws, 
14 


2IO  OPERATIONS    UPON    THE    LIDS 

which,  to  be  ri.yht,  arc  rather  broad — two  to  three  milHrneters — 
slightly  rounded  at  the  corners  and  of  faultless  coaptation.  The 
depth  of  the  articulating  surface  is  about  one  and  one-half  milli- 
meters and  the  width,  of  course,  the  same  as  that  of  the  jaw  itself. 
The  shanks  arc  sufficiently  rigid  to  withstand  the  necessary  pressure 


Fic.  ()S. — T>i(l  cvcrtc'd  and  hrld  l>y  iliunil)  on  lashes. 

without  bending  toward  each  otlier,  as  this  would  cause  the  ti])S 
of  the  jaws  to  open,  sa\'e  at  their  posterior  angles,  and  to  Icl  go  the 
hair. 

Lindsay  Johnson^  recommends  putting  a  minute  (|uaniity  of 
cobler's  wax,  or  resin,  between  the  opposing  jaws  of  the  forceps,  and 

'  ()])lithalmoscopc,  Nov.,  1904. 


KIMI.ATION 


genlly  heating  for  a  second.  The  material  will  spread  evenly  over 
the  blades  and  insure  a  lirm  gri])  on  the  hair.  It  can  be  melted  and 
wiped  off  for  cleansing  or  renewing. 


Fig.  ()(). — Handle  of  instrument  as  aid  in  everling  lid. 


The  Method. — Epilation,  like  eversion,  while  it  can  be  done, 
after  a  fashion,  by  the  merest  novice,  has,  nevertheless,  its  refine- 
ments and  is  cleverly  done  only  by  those  who  have  special  training. 
The  forceps  is  held  between  the  tips  of  the  right  thumb  and  index, 


212  OPERATIONS    UPON    THE    LIDS 

jaws  up  for  the  upper  lid  and  down  for  the  lower.  The  bulbs  of 
the  left  lingers  are  rested  on  the  patient's  brow,  he  is  made  to 
look  down  for  epilation  of  the  upper  lid,  and  vice  versa.  The  left 
thumb  manipulates  the  upper  lid,  the  left  index  the  lower,  slightly 
everting  by  pressure,  raising,  depressing,  etc.  The  jaws  are  placed 
vertically  astride  the  hair  to  be  pulled  and  in  contact  with  the  skin 
at  its  base,  closed — not  too  tightly — and  gentle,  steady  traction 
made  exactly  in  the  line  of  the  shaft  of  the  cilium,  to  pluck  it  out 
by  the  root.  Quick  jerks  and  sidewise  pulls  will  not  do,  but  result 
in  breaking  off,  not  eradicating.  The  hairs,  especially  the  tiny 
ones,  seem  to  require  a  little  time  in  which  to  relinquish  their 
deeper  attachments.  The  smaller  the  hair,  a:pparently,  the  stumpier 
the  free  end,  hence  those  that  are  practically  invisible  to  the 
naked  eye  are  almost  as  potent  for  harm  when  they  touch  the  cornea 
as  are  the  larger  ones.  Focal  illumination  made  by  an  assistant  or 
by  the  adjustable  lens,  attached  to  a  head-band  are  valuable  ad- 
juncts. For  locating  the  liner  ciha  the  lid  must  be  so  managed 
that  the  pupil,  iris,  or  nearly  closed  palpebral  fissure  will  afford  a 
dark  background  for  the  illumined  hair.  Strong  convex  spec- 
tacles, or  the  binocular  loop,  worn  by  the  operator  will  greatly 
assist  him.  With  all  these  appliances  certain  extremely  fine  hairs 
will  remain  invisible  and  must  be  nipped  for  cautiously  along  the 
whole  length  of  the  lid.  When  the  resistance  of  one  is  felt  or  a 
pimple  is  seen  to  rise  around  it  the  usual  time  is  given  for  it  to  let 
loose. 

A  wad  of  absorbent  cotton  that  has  been  moistened  with  boric 
acid  or  sublimate  solution  and  well  wrung  is  held  on  the  brow 
beneath  the  fingers  of  the  left  hand  on  which  to  wipe,  the  forceps. 
As  the  eye  fills  with  tears,  the  lids  are  sponged  dry  from  time  to 
time,  for  the  forceps  will  not  hold  the  cilia  securely  when  they  are 
wet. 

Electrolysis  of  the  hair-follicles,  something  after  the  method 
of  Michel,  1  as  an  auxiliary  to  epilation,  is  the  only  sure  means  of 
permanently  eradicating  the  cilia,  and  is  particularly  applicable  to 
cases  of  trichiasis  where  relatively  few  hairs  grow  inward,  or,  as  it 
is  termed,  distichiasis. 

The  requisite  implements  are  an  electric  outfit,  capable  of 
furnishing  a  continuous  current  of  from  one  to  five  milliamperes. 

'  St.  Louis  Clinical  Record,  Oct.,  1875. 


IIORDKOLUM    AND    CHALAZION  213 

The  negative  electrode  is  filled  willi  a  fine,  sliarj)  ncTdlc  (f^old  or 
platinum),  the  positive,  with  a  s])()n,^e  which  is  moislcncd  with  salt 
solution.  Provided  there  is  a  rhcoslal  or  controlling  switch,  one 
may  dispense  with  a  galvanometer;  indeed,  the  best  means  of  regu- 
lating the  energy  is  to  immerse  the  two  electrodes  in  a  vessel  of  water 
and  gradually  turn  on  the  current  until  the  needle  throws  off  a 
stream  of  tiny  bubbles,  indicatixe  of  the  decomposition  of  the 
liquid.  It  is  then  ready  for  use.  A  valuable  suggestion  is  that 
of  Jourdan,  of  Frankfort  a/M.,  to  apply  shellac  to  the  needle,  then 
to  uncover  the  point  by  scraping.  This  greatly  lessens  the  j)ain, 
since  it  protects  the  sensitive  skin.  It  also  pre\ents  ])unctiform 
scars  that  might  otherwise  ensue. 

In  order  to  introduce  the  needle  with  precision  the  operator 
wears  strong,  convex  lenses  or  uses  the  binocular,  stereoscopic 
loop.  The  patient  may  sit  or  lie.  A  lid  spatula  is  inserted  beneath 
the  lid  to  steady  it  and  to  afford  a  purchase  for  holding  and  manip- 
ulating with  the  thumb.  Or,  better  still,  the  Beard  lid-forceps  is 
clamped  on  (Fig.  loo).  The  needle  is  pushed  down  alongside  the  shaft 
of  the  hair,  till  the  point  is  well  within  the  follicle  (three  to  four  mil- 
limeters) and  the  sponge  electrode  is  applied  to  the  adjacent  temple 
or  forehead.  As  soon  as  a  boiling  up  of  gas  occurs  around  the 
needle,  the  sponge  is  lifted,  or  the  connection  button  is  released, 
the  needle  withdrawn  and  the  hair  lifted  out.  Lifted  is  the  word, 
for  if  any  traction  is  needed,  it  is  a  sign  that  the  electrolysis  has  been 
incomplete  and,  to  be  effective,  must  be  repeated.  The  performance 
is  anything  but  agreeable  to  the  victim,  but  the  pain  is  much  greater 
if  the  needle  is  taken  out  without  stopping  the  current. 

Hordeolum. — When  this  affection  has  reached  the  stage  of 
abscess  and  has  not  ruptured  spontaneously  it  is  customary  to  make 
an  incision.  For  this  either  the  Beer  or  the  Graefe  knife  is  suitable. 
The  chief  precaution  to  iK'ar  in  mind  in  this  connection  is  to  avoid 
needless  traumatism  of  the  tarsus,  as  the  cicatrices  thus  left  often 
give  rise  to  cysts  or  chalazions.  The  opening  is,  therefore,  preferably 
made  through  the  skin. 

Chalazion. — The  usual  manner  of  removal  is  by  incision  and 
curettage.     The  tumor  is  attacked  from  one  of  three  directions: 

1.  Marginal  Route.— From  the  free  border  (Agnew). 

2.  Conjunctival  Route. — From  the  inner  surface  of  the  lid. 

3.  Cutaneous  Route. — From  the  external  surface  of  the  lid. 
The  first  is  preferable  for  the  removal  of  the  softer  or  cysloid  varieties 


214 


OPERATIONS    UPON    THE    LIDS 


parlicularly,  when  not  siUuUed  in  the  extreme  ui)per  portion  of  the 
superior  tarsus. 

The  only  lustnimcnts  needed  are  a  thin,  sharp  Beer's  knife  or 
a  straight,  keen  bistoury  and  a  small,  oblong  sharp  curet.  A  drop 
of  cocain  solution  is  instilled. 

The  positions  of  surgeon  and  subject,  as  concerns  the  upper  lid 
(Fig.  roi),  are  the  same  as  for  slitting  and  syringing  the  lower  canalic- 


l-'iG.  loo. — Electrolysis  of  cilia. 


ulus  ( p.  125).  The  lid  is  slightly  lifted  from  the  globe  by  catching  hold 
of  the  lashes  with  the  right  hand,  the  left  forefinger  is  slid  beneath, 
with  the  palmer  tip  in  contact  with  the  tumor,  the  left  thumb  is  put 
in  contact  with  it  on  the  outside  and  it  is  held  as  one  would  a  pea — 
in  other  words,  as  if  the  surroundings  of  the  tumor  did  not  exist — 
and  this  hold  is  maintained  throughout  the  entire  operation.  The 
lid  is  turned  slightly  away  from  the  eye  and  the  incision  is  made 
exactly  in  the  mid-line  of  the  free  border  of  the  tarsus,  the  tlat  of  the 
blade  corresponding  to  the  flat  of  the  lid,  and  the  point  aimed  at  the 
center  of  the  tumor.  Having  |jenetrated  the  chalazion,  the  knife 
is  rocked  slightly,  to  insure  free  opening  of  the  wall,  and,  in  with- 
drawing, the  soft  contents  are  squeezed  out  by  pressing  together  the 


OPERATIONS    FOR    CHALAZION 


Fig.  ioi. — Agnew's  incision  for  chalazion. 


2l6  OPERATIONS    UPON    THE    LIDS 

left  finger  and  thumb.  Still  grasping  the  tumor,  the  tiny  serrated 
curet  is  introduced,  the  unexpressed  contents  laded  out  and  the 
walls  of  the  cavity  well  scraped.  The  left  finger  and  thumb 
feel  the  movements  of  the  curet  and  are  a  guide  to  its  work.  As  the 
instrument  is  removed,  they  are  approached  to  hold  the  opposite 
sides  of  the  opening  tightly  together  and  thus  held  for  a  few  moments, 
else  it  would  fill  with  blood  and  tend  to  disparage  the  result.  The 
materials  for  applying  a  compressive  bandage  are  ready  at  hand,  so 
that  as  the  lid  is  let  go,  the  occluding  pad,  with  its  facing  layer  of 
wet  cotton,  is  applied,  and  the  simple  bandage  (p.  i6)  tied  over  it. 
This  can  be  done  in  such  a  way  that  there  will  be  no  let  up  in  the 
pressure  upon  the  site  of  the  chalazion,  hence  no  possibility  of  a 
blood  tumor  forming.  Twelve  hours  is  long  enough  for  the  bandage 
to  be  worn,  after  which  simply  bathing  the  eye  with  hot  water  is 
sufhcient.  The  advantages  of  Agnew's  method  are  simplicity  and 
the  leaving  of  neither  a  visible  scar  of  the  skin,  nor  an  irritating  one 
of  the  conjunctiva. 

Wilder,  of  Chicago,  has  invented  a  lid-clamp,  shaped  like  the 
letter  U  (Plate  IV,  No.  79).  With  this  he  surrounds  the  chalazion, 
then  injects  a  few  drops  of  cocain  solution  through  the  border  of  the 
lid  into  the  tumor.  The  clamp  serves  both  to  keep  the  cocain 
from  entering  the  general  circulation  and  to  prevent  hemorrhage, 
while  the  cocain  renders  the  cutting  and  curetting  painless.  A 
drop  of  the  solution  previously  put  on  the  underlying  conjunctiva 
also  helps  to  do  away  with  the  pain  of  the  clamp. 

Removal  from  the  inner  surface  of  the  tarsus,  although  the  favorite 
mode  with  a  few  operators,  is  chiefly  indicated  when  the  inflam- 
matory process  has  gone  so  far  in  that  direction  as  to  have  produced 
either  a  spontaneous  opening  or  the  sprouting  up  of  granulation 
masses.  An  incision  is  not  necessary  in  most  instances,  merely 
eversion  of  the  lid,  cocain  and  a  drop  of  adrenalin,  and  thorough 
curettage.  A  clamp  and  sutures  are  uncalled  for.  Other  indica- 
tions than  those  just  alluded  to  hardly  exist  for  the  method  in  ques- 
tion, seeing  that  either  the  marginal  or  the  cutaneous  modes  offer 
superior  results.  In  truth,  large  chalazions,  extirpated  from  the 
conjunctival  side,   have  been  followed  by  troublesome  trichiasis. 

The  cutaneous  opening  is  resorted  to  by  many  as  a  customary 
procedure,  and  has  certain  advantages.  For  the  hard,  fibroid 
chalazions  and  those  softer  ones  whose  seats  are  high  up  in  the 
superior  tarsus,  tliis  is  by  far  the  best  mctliod. 


CANTHOPLASTY  217 

The  instruments  needed  are  a  lid  clamp  (Desmarre's,  Plate  VI, 
is  probably  the  most  suitable,  but  Snellen's  also  answers  well)  small, 
mouse-tooth  forceps,  small  scalpel  or  bistoury,  Steven's  strabismus 
hooks,  small,  blunt  scissors,  needle  forceps,  and  a  fine  curved 
needle,  carrying  No.  i  braided  silk  thread.  Narcosis  would  be 
admissible  only  in  case  of  a  child,  either  in  years  or  nerves. 

A  drop  of  cocain  solution  is  put  into  the  eye  to  make  it  tolerant 
of  the  clamp.  The  plate  of  the  latter  is  slid  beneath  the  lid,  the  ring 
made  to  encircle  the  chalazion  and  the  screw  tightened.  This  ap- 
pliance insures  hemostasis  and  steadies  the  field  of  operation. 
The  hard,  rubber  lid  spatula  may  be  substituted  for  the  clamp, 
but  it  must  be  held  by  an  assistant.  A  transverse  incision  is  made 
(that  is,  parallel  with  the  free  border)  over  the  tumor  and  extending 
a  short  distance  beyond  it  at  each  end  through  integument  and 
orbicularis,  down  to  the  tarsus,  and  held  open  by  the  little  strabismus 
hooks.  The  fibres  of  the  muscle  are  pushed  aside,  the  tumor  seized 
with  the  forceps,  or  a  minimum-size,  short  tenaculum  does  equally 
well,  and  dissected  with  knife  and  scissors  much  as  one  would  shell 
out  a  sebaceous  cyst.  If  practicable,  the  conjunctiva  beneath  the 
chalazion  is  left  intact,  but  no  part  of  the  abnormal  growth  is  left 
behind  in  order  to  avoid  making  a  hole  clear  through,  as  to  do  so 
would  do  no  special  harm.  The  opening  is  cleansed,  but  not  until 
after  the  removal  of  the  clamp  and  the  stanching  of  the  blood  is  the 
suture  introduced.  One  suffices,  and  it  is  taken  out  after  twenty- 
four  to  thirty-six  hours.  The  dressing  may  be  the  regulation 
bandage,  a  patch,  or  adhesive  strips. 

Canthoplasty. — Technically,  this  word  signifies  an  operation  for 
the  correction  of  an  anomalous  condition  of  the  commissure — 
usually  the  outer — of  the  lids  and  is  to  be  distinguished  from  canthot- 
omy  or  tarsodialysis,  which  means  merely  a  cutting  of  the  canthus. 
According  to  its  common  acceptation,  however,  the  term  is  used  in 
both  senses,  yet  with  this  difference;  simple  incision  of  the  canthus, 
without  the  addition  of  sutures,  is  called  provisional  canthoplasty; 
and  the  more  finished  operation,  wherein  there  is  external  tenotomy 
oculi  and  the  divided  conjunctiva  and  skin  are  stitched  together  or 
yet  further  elaborated,  is  known  as  definitive  canthoplasty. 

The  Jirst  is  applied,  for  example,  to  the  temporary  elongation  of 
the  palpebral  fissure  that  is  made  preliminary  to  exenteration  of 
the  orbit,  to  the  enucleation  of  a  globe  of  extra  size,  to  the  extraction 
of  cataract  where  the  conjunctival  sac  is  much  shrunken,  and  to 


2l8  OPERATIONS    UPON   THE    LIDS 

relieve  pressure,  as  in  phlegmon  of  the  orbit,  in  the  intense  chemosis 
of  gonorrheal  ophthalmia,  and  in  panophthalmitis. 

The  second,  to  permanent  extension  of  the  outer  commissure  for 
the  correction  of  blepharophimosis,  for  anchyloblepharon,  and  for 
the  damaging  lid  tension  in  chronic  trachoma.  It  is  also  an  im- 
portant part  of  many  operations  for  entropion  and  is  occasionally 
the  sole  measure  adopted  for  the  cure  of  spastic  entropion.  It  may 
be  stated  in  passing  that  canthotomy,  pure  and  simple,  is  seldom 
practised  nowadays,  as  even  in  most  of  the  instances  just  given  it  is 
followed  by  sutures.  C.  R.  Agnew,  of  New  York,  in  1875,  was  the 
first  to  demonstrate  the  immense  value  of  canthoplasty  as  a  thera- 
peutic measure  in  inflammations  of  the  conjunctiva  and  cornea, 
such  as  the  more  severe  phases  of  phlyctenular  and  interstitial 
keratitis  and  trachoma. 

Agnew's  method,  or  cantholysis,  a  modification  of  that  devised 
.by  Von  Amnion  in  1839,  and  the  one  chiefly  in  vogue  among 
American  surgeons,  is  here  described. 

The  instruments  comprise  large  and  small  straight,  blunt  scissors 
(Plate  IV,  Nos.  53  and  55),  mouse-tooth  forceps,  needle-holder, 
and  two  or  three  fine  curved  needles.  General  anesthesia  only  when 
absolutely  necessary.  Local  anesthetics  help  slightly.  The  patient 
lies  on  the  table. 

First  Step. — The  canthotomy.  The  outer  commissure  is  held 
moderately  open  by  the  left  thumb  and  index,  one  blade  of  the  large 
scissors  is  slid  into  the  outer  cul-de-sac  as  far  as  it  will  readily  go,  its 
edge  exactly  beneath  the  angle  of  the  lids  and  in  line  with  the  closed 
palpebral  fissure.  The  other  blade  is  closed  down  until  it  touches 
the  skin,  a  good  grip  is  taken  on  the  handles,  so  that  the-blades  will 
not  "buckle,"  and  with  one  firm  snip  the  cut  is  made.  This  should 
be  from  one  to  one  and  a  half  centimeters  long,  according  to  the  de- 
mands of  the  case.  Although  the  cut  is  usually  made  in  a  perfectly 
horizontal  direction,  it  would  seem  that  in  many  individuals  the  scar 
would  conform  better  to  the  natural  topography  about  the  outer 
canthus  if  it  were  given  a  somewhat  downward  inclination.  One 
should  l;ear  in  mind  that  a  part  of  the  accessory  lacrimal  gland  lies 
in  this  region  and  strive  not  to  injure  it  wantonly.  There  will  be 
some  bleeding,  but  it  usually  ceases  spontaneously. 

Second  Step. — ^Division  of  the  external  canthal  ligament. — The 
free  border  of  I  he  upper  lid  is  grasped  by  the  left  thumb  and  index, 
pushed  slightly  up  to  oj)en  the  spaces  between  the  severed  skin  and 


CANTHOPLASTY  219 

conjunctiva,  and  the  small  scissors,  closed,  are  put  into  the  upj)er 
opening  to  feel  for  the  ligament.  The  lid  is  now  pulled  forward  and 
toward  the  nose,  so  as  to  make  the  ligament  taut,  when  the  scissors 
are  opened  shghtly,  the  blades  are  pushed  up  astride  the  ligament 
and  it  also  is  cut  with  a  single  snip.  Some  authors  state  that  the 
conjunctiva  is  unavoidably  incised  in  dividing  the  ligament;  such 
is  not  the  case,  for  with  dehcate  scissors  and  a  little  care,  neither 
the  skin  nor  the  conjunctiva  need  be  wounded.  If  the  snip  is  suc- 
cessful the  lid  at  once  gives  way  under  thumb  and  finger.  If  it 
fails  thus  to  yield,  another  and  more  careful  effort  must  be 
made.  The  same  procedure  is  repeated  on  the  lower  section  of  the 
ligament. 

Third  Step.— Placing  and  tying  the  sutures.— An  assistant  opens 
wide  the  extended  commissure.  It  wall  be  observed  that  the  cut  in 
the  skin  is  longer— often  very  much  so— than  that  in  the  conjunctiva. 
Now,  all  the  descriptions  of  the  operation  that  I  have  ever  read,  and 
all  the  many  cuts  that  I  have  seen  illustrative  of  it,  teach  that  the 
angle  of  the  conjunctival  opening  should  be  joined  to  that  of  the  skin. 
This  is  precisely  what  Agnew  insisted  should  not  be  done,  and  ui)on 
substantial  grounds;  for,  owing  to  the  inequality  in  the  length  of 
the  angles  alluded  to,  thus  to  unite  them,  means  the  obliteration  of 
the  external  cul-de-sac,  not  only  this,  but  it  would  require  so 
much  stretching  of  the  conjuctiva  to  make  it  meet  the  skin  at 
this  point  that  an  unseemly  bridle  or  band  would  result, 
the  same  becoming  particularly  noticeable  and  restricting  with 
the  globe  in  adduction.  Therefore,  following  Agnew,  after  picking 
up  the  conjunctival  angle  with  the  needle,  it  is  carried  outward 
as  far  as  it  will  go  without  any  stretching  and  is  joined  to  the 
upper  lip  of  the  incision  (Fig.  102) .  Another  suture  is  placed  to  unite 
the  lower  skin  and  mucous  lips,  and  sometimes  a  third  to  perform 
the  same  office  above,  and  the  operation  is  finished— unless,  per- 
chance, one  chooses  to  put  in  a  fourth  or  superficial  suture  to  close 
the  small  skin  angle  thus  left  unclosed.  As  each  suture  is  put  in,  if  it 
be  not  tied  at  once,  but  the  two  ends  of  thread  are  laid  together  on  the 
temple  where  an  aid  places  a  finger  on  them  to  insure  keeping  them 
to  themselves.  They  are  tied  with  the  canthus  stretched  open,  in 
order  to  see  that  they  are  true  and  do  not  cut  out  of  the  conjunctiva. 

Several  other  ingenious  and  effective  varieties  of  canthoplasty 
have  been  devised  and  extensively  practised.  Attention  is  called 
to  three: 


OPERATIONS    UPON    THE    LIDS 


1.  Richet^  resected  a  dart  of  skin  and  tarso-orbital  fascia  whose 
base  was  the  canthus  and  whose  point  reached  outward  horizon- 
tally one  and  one-half  centimeters.  A  median  horizontal  incision 
was  made  in  the  outer  wall  of  the  external  conjunctival  cul-de-sac 
thus  laid  bare,  and  the  cut  edges  were  stitched  to  those  of  the  skin. 

2.  David  Prince, 2  of  Jacksonville,  111.,  made  a  cutaneous  incision, 
beginning  on  a  level  with,  and  three  or  four  centimeters  from  the 
commissure,  down  and  in,  parallel  with  the  lower  lid  border,  one- 
third  to  one-half  of  the  length  of  the  latter;  then  from  this  point 
out  and  up  back  to  the 
level  of  the  canthus,  but 
several  millmeters  fur- 
ther toward  the  temple. 
The  curved  angle  of  skin 
thus  marked  out  was 
dissected  up  from  apex 
to  base.  A  third  inci- 
sion joined  this  base 
and  the  canthus,  the 
upper  lip  of  which  was 
undermined  for  a  centi- 
meter or  more  toward 
the  brow,  a  double- 
armed  suture  was  put 
through  the  point  of  the 
curved  flap  outhned  by  the  first  two  incisions;  it  was  tucked  up  into 
the  pocket  made  by  the  undermining  of  the  upper  lip  of  the  hori- 
zontal incision,  the  suture  brought  out  through  the  skin  beneath 
the  supercilia  and  tied  over  cylinders  of  buckskin  or  other  material. 
The  remaining  angular  opening  was  closed  by  sutures,  which  com- 
pleted a  clever  method  for  combining  canthoplasty  with  correction 
of  moderate  ectropion  of   the  lower  lid. 

3.  Chalot  (V.)^  makes  an  incision  through  the  skin  only,  extending 
from  the  canthus  outward  one  and  one-half  centimeters.  This 
he  crosses  with  a  vertical  skin  incision,  made  flush  with  the  canthus, 
the  two  forming  a  capital  H  ,  supine,  against  the  canthus.  The 
two  angles  he  dissects  or  undermines,  exposing  a  bridge  of  conjunc- 


FiG.  102. — Canthoplasty.     Von  Amnion- Agnew. 


'  Trait,  d'anat.  med.  chir.,  1851. 

-  Am.  Jour,  of  the  Med.  Sciences,  1866,  p.  381. 

^  Trait.  Elem.  dc  Cliir.  ct  de  Med.,  Paris,  iqoo,  3d  edition,  p.  7: 


TARSORRHAPHY  22  1 

tiva.     This  is  incised  above  and  below,  turned  outward,  and  sutured 
to  the  angle  of  the  cutaneous  incision. 

Tarsorrhaphy,  or  as  it  is  sometimes  termed,  blepharorrhaphy,  is 
an  operation  having  for  its  object  the  occlusion  of  all  or  a  portion 
(total  tarsorrhaphy,  or  partial  tarsorrhaphy)  of  the  palpebral 
fissure.  It  is  called  external,  median,  or  internal,  respectively,  as  it 
concerns  the  corresponding  division  of  the  fissure.  Internal  tar- 
sorrhaphy is  sometimes  erroneously  called  median,  after  the  German 
fashion.  Like  canthoplasty,  the  end  sought  may  be  a  permanent  one 
(definite  tarsorrhaphy)  or  temporary  (provisional  tarsorrhaphy). 

Some  phase  of  the  operation  is  sometimes  indicated  in  lagoph- 
thalmos  (paralysis  of  the  seventh  nerve  with  ectropion),  in  neuro- 
paralytic keratitis  (paralysis  of  the  fifth  nerve),  in  certain  forms  of 
reducible  exophthalmos,  and  in  traumatic  proptosis.  It  is  also  helpful 
in  preventing  cicatricial  ectropion  after  skin  lesions  of  the  lids,  such 
as  burns,  blastomycosis,  etc.,  in  stopping  threatened  staphyloma  of 
the  cornea,  and,  occasionally,  as  an  adjunct  to  surgery  undertaken 
for  the  restoration  of  the  lids  and  conjunctiva,  to  hold  them  in 
position  during  the  healing  process. 

Total  tarsorrhaphy,  literally  speaking,  either  temporary  or 
permanent,  is  not  admissible,  since  in  the  first  instance  it  means 
difficulty  of  reopening  the  outer  canthus  should  this  become 
desirable  later,  and  in  the  second,  retention  of  the  secretions  of  the 
eye.  A  more  or  less  extensive  median  operation  is  better  in  botli 
instances. 

External  tarsorrhaphy.  Occlusion  of  the  outer  portion  of 
the  fissure,  as  first  i)raciiced  by  Walther,  was  frequently  resorted 
to  previous  to  the  invention  of  the  median  method.  It  was  done 
by  "scalping"  the  fids  or  excising  strips  of  skin  containing  the 
follicles  of  the  cilia  (Fig.  103)  from  the  outer  canthus  for  varying 
distances  inward,  owing  to  the  degree  of  closure  desired  and  uniting 
the  raw  edges  by  sutures.  The  method  is  still  resorted  to,  at  times, 
as  a  permanent  feature,  especially  in  connection  with  operations 
for  the  correction  of  ectropion  of  the  lower  lid,  from  laxness,  and 
with  eversion  of  the  punctum;  but  it  should  never  be  done  if  one  ex- 
pects later  to  undo  the  work. 

Fuchs  is  the  author  of  a  method  of  external  tarsorrhaphy  that 
could  be  converted  into  internal,  and  which  is  characterized  by 
great  solidity  of  the  union  produced  between  the  lids  (Fig.  104). 
Brieflv,  it  is  thus:   beginning  at  the  outer  canthus  and  extending 


22  2  OPERATIONS    UPON    THE    LIDS 

inward  the  desired  distance,  an  intcrmarginal  incision  is  made, 
whereby  the  Hd  is  spht  for  a  depth  of  live  or  six  miUimeters  into 
tarsal  and  cutaneous  leaves.  At  the  inner  end  of  the  sHt  a  vertical 
incision  is  made  in  the  skin  half  that  extends  to  the  bottom  of  the 
slit  to  allow  the  latter  to  gape.  Corresponding  incisions  are  made 
in  the  upper  lid  with  the  addition  of  a  second  perpendicular  inci- 
sion in  the  skin  half  at  the  canthus.  The  upper  extremities  of 
the  two  vertical  cuts  are  joined  by  an  incision,  and  the  paral- 
lelogram thus  outlined,  and  which  contains  the  hair  bulbs,  is  ex- 
cised. A  double-armed  suture  is  passed  from  within  outward  at 
the  middle  of  the  denuded  portion  of  the  upper  tarsus  and,  in  the 


Fig.  103. — External  tarsorrhaphy. 
(Walthcr.) 


Fig.  io4.^Fuchs'  external  tarsorrhaphy. 


same  manner,  through  the  skin  flap  of  the  lower  lid  and  tied  over  a 
cylinder  of,  some  appropriate  material.  In  closing  the  lids  and 
knotting  the  thread  the  inner  surface  of  the  loosened  skin  flap  is 
made  to  coapt  with  the  raw  surface  of  the  upper  tarsus.  To  com- 
plete the  operation,  a  few,  flne,  superficial  sutures  are  put  in. 

Internal  tarsorrhaphy,  or  Canthorrhaphy,  was  first  resorted 
to  for  the  exophthalmos  that  so  often  followed  the  too  free  tenotomies 
which  characterized  the  earlier  operations  for  strabismus.  It  w^as 
revived,  and  its  technic  improved  by  Von  Arlt,  who  called  it  median 
tarsorrhaphy  to  distinguish  it  from  external  t.  then  the  only  other 
kind.  Arlt  a])])nf(l  it  to  those  slight  degrees  of  ectropion  of  the 
lower  lid,  with  cNtTsion,    or  noncontact,  of  the  ])unctuni,  thai  arc 


MEDIAN    TARSORRIIAI'IIV 


223 


SO  j)ro\-()cati\-c  of  annoyinji;  c|)i{)h()ra,  and  that  arc  so  unsatisfac- 
tory as  to  their  trcatnunt  by  conservative  means.  It  is  here  that 
the  measure  still  Inids  its  chief  indication,  th()u<!;h  it  is  preferred 
by  some  to  the  external  and  median  forms  for  lagophthalmos, 
and  is  less  disfiguring.  It  is  also  useful  for  the  sagging  of  the 
lower  lid  in  operative  anophthalmos,  and  which  precludes  the 
wearing  of  an  artificial  eye.  It  consisted  in  the  resection  of  a 
horseshoe-shaped  strip  of  skin  around  the  lac  lacrymale  close  to, 
and  surrounding  the  inner  canthus  and  uniting  the  upper  and 
lower  halves  by  sutures,  thus  preserving  the  puncta  and  can- 
aliculi — a  sort  of  artificial  ejjicanthus  (Fig.  105).     All  that  is  neces- 


FiG.  105. — Internal  tarsorrhaphy 


sary  is  to  close  the  semicircle  that  constitutes  the  canthus  itself— 
or,  what  the  French  call  "the  grand  angle."  This  is  accomplished 
by  paring  with  delicate  curved  scissors  a  very  narrow  strip,  just 
where  skin  and  conjunctiva  meet,  rather  inclining  to  the  skin  side, 
being  scrupulous  to  avoid  wounding  the  canaliculi  and  to  stop 
safely  short  of  reaching  the  puncta.  The  opposite  raw  surfaces  are 
united  by  fine  interrupted  sutures,  which  are  removed  at  the  end  of 
two  or  three  days. 

Median  tarsorrhaphy  (Fig.  106),  or  the  forced  agglutination 
(more  or  less  extended)  of  the  opposing  surfaces  of  the  lid  borders 
at  or  near  the  center  of  the  palpebral  fissure,  was  first  done  by  Bow- 
man; but  to  Panas  is  due  the  credit  of  devising  the  improved  mode. 
It  is  a  most  useful  operation,  whether  provisional  or  definitive, 
and  is  made  as  follows : 

The    lids  having  been  carefully   approximated,  one  selects  the 


224 


OPERATIONS    UPON    THE    LIDS 


location  and  marks  the  extent  of  the  proposed  occlusion.  The 
best  way  is  by  means  of  tiny  pricks  with  knife,  to  cause  red  points  of 
blood.  If  the  eye  has  useful  vision,  the  site  of  the  operation  is 
so  placed  that  in  looking  at  distant  objects  the  outer  opening  is 
utilized,  and  at  those  close  up,  the  inner  one.  This  would  make  the 
occluding  bridge  a  trifle  to  the  nasal  side  of  the  center,  the  point 
that  is  preferable  from  an  anatomical  standpoint  also.  A  lid 
spatula  is  placed  first  in  the  lower  fornix,  for  when  the  upper  lid 
is  done  first  the  bleeding  interferes  with  work  on  the  lower.     The 

lid  is  pressed  firmly  against 
the  spatula  to  steady  it  if 
no  clamp  is  used,  and  a  thin 
slice  of  the  margin  is  re- 
moved by  means  of  the 
convex  scalpel.  I  have 
found  the  Beard  forceps 
described  on  page  99  the 
most  convenient  instru- 
ment for  steadying  the  lid 
during  this  step.  It  is  ap- 
plied just  as  if  for  making 
the  intermarginal  incision 
for  receiving  a  graft,  the  screw  tightened,  and  the  lid  everted.  The 
raw  surface  prepared  need  not  be  more  than  four  or  five  millimeters 
long,  though  this  must  be  regulated  by  the  judgment  of  the  operator. 
Its  width  should  include  only  the  tarsal  partion  of  the  free  border, 
i.e.,  the  adjacent  cilia  and  their  follicles  are  spared.  An  exactly 
contiguous  spot  is  pared  on  the  upper  margin.  Two  sutures  are 
passed  in  through  the  lower  lid  and  out  through  the  upper,  the  raw 
areas  put  nicely  in  apposition  and  the  thread  tied  firmly  oxer  a 
short  section  of  soft-rubber  tubing  or  a  cylinder  of  gauze  or  cotton. 
It  is  best  to  reinforce  the  sutures  by  strips  of  adhesive  plaster. 
Over  all,  the  usual  dressing  and  bandage.  The  spring  of  the  rub- 
ber tubing  will  take  up  the  slack  of  the  thread  caused  by  any 
slight  tendency  to  cut  out;  yet,  to  make  surer,  one  may  tie  bow- 
knots,  so  that  they  may  be  untied,  in  case  of  early  separation  of  the 
lids,  and  the  sutures  again  drawn  up.  The  thread  is  removed 
after  four  or  five  days. 

In  course  of  time  the  free  portions  of  the  lid  borders,  although 
closed  at  first,  ])ecome  curved  or  concave,  causing  two  clHi)tical 


Fig.   106. — Median  tarsorrhaphy. 


EXSECTION  OF  THE  TARSUS  225 

openings  which  serve  achiiirably  for  \ision — tlic  outer  for  distant  and 
the  inner  for  near,  yet  not  sufficiently  wide  to  give  rise  to  trouble 
with  the  cornea  (Fig.  107). 

Exsection  of  the  Tarsus. — The  cutting  out  of  all  or  a  portion 
of  a  diseased  tarsus  was  done  as  far  back  as  the  Middle  Ages.  It 
was  first  undertaken  for  the  relief  of  cicatricial  entropion.  To  this 
end,  Saunders^  in  cases  of  shrunken  and  incurvated  tarsi,  removed 
them  entirely.  In  this  con- 
nection, the  procedure  has 
been  superseded  by  modern 
methods,  as  described  under 
Entropion.  The  operation 
is  resorted  to  after  fair  trial 
of  other  means  of  treatment 
has  failed  to  effect  a  cure  or 
when  the  circumstances  are       „  r>     u   f       r     <         ]     1 

Fig.  107. — Result  of  median  tarsorrhaph}-. 

such  that   the  other  means 

cannot  be  consistently  carried  out.  It  is  indicated  in  the  severe 
tarsal  form.s  of  vernal  catarrh  and  in  obstinate  chronic  trachoma 
characterized  by  deep  infiltration  and  hypertrophy  and  degenera- 
tion of  the  tarsus,  accompanied  by  persistent  pannus  and  recurrent 
corneal  ulcers.      (For  description  see  page  372.) 

C.  Magnani,^  of  Smyrna,  as  a  precaution  against  ptosis,  after  the 
operation,  before  tying  the  threads  to  close  the  wound,  opens  it 
wide  and  puts  a  double  armed  suture  into  the  deeper  portion  of 
Miiller's  muscle,  then  carries  the  needles  up  and  back  (lid  inverted), 
and  causes  them  to  emerge  from  the  skin  near  the  cilia.  He,  then, 
closes  the  wound,  turns  the  lid  back  into  position,  and,  lastly,  ties 
the  external  thread  ends  over  a  tiny  glass  bead.  If  the  operation 
is  done  after  the  manner  here  described,  however,  there  is  no 
extra  inclination  to  ptosis.  It  will  be  remembered  that  there  is  an 
inherent  tendency  in  many  of  these  chronically  inflamed  lids  to 
both  ptosis  and  entropion. 

The  usual  dressing  is  applied,  lliough  wliether  to  one  or  both 
eyes  is  a  matter  which  is  left  to  the  judgment  of  the  operator. 
If  there  are  knotted  threads  touching  the  cornea,  both  eyes  should 
be  bandaged,  the  better  to  insure  immobility  of  the  globes. 
The  sutures  are  removed  on  the  fourth  day. 

1  Treatise  on  Diseases  of  the  Eye,  181  i. 

2  La  Clinica  Oculistica,  Oct.,  igo.^,  ji.  1460. 

IS 


226 


OPERATIONS    UPON    THE    LIDS 


Operations  for  Epicanthus,  or  Rhinorraphy. — Von  Amnion^ 
first  described  this  congenital  deformity  of  the  nose  and  disfigure- 
ment of  the  inner  canthi  under  the  name  it  bears,  and  invented  an 
operation  for  the  correction  of  the  ocuLir  part  of  the  defect  which  he 
called  rhinorraphy.  This  consisted  in  pinching  up  a  vertical  fold 
of  skin  on  the  bridge  of  the  nose  sufficient  to  rid  the  canthi  of  the 
redundance,  marking  out  the  base  of  the  fold  in  ink,  excising  it, 
inserting  silver  pins,  as  in  the  operation  for  harelip,  and  closing 


Fig.  io8. — Knapp's  Rhinorraph} 


the  opening  by  means  of  thread  wound  on  to  the  pins,  figure-8 
fashion.     This  is  known  as  median  rhinorraphy. 

De  Wecker^  modified  the  operation  by  putting  two  or  three  large, 
curved,  threaded  needles  through  the  base  of  the  pinch-up  fold,  in- 
stead of  outlining  it.  He  then  cut  it  out  with  scissors  close  to  the 
needles,  and  brought  together  the  edges  of  skin  with  the  threads. 

Knapp^  still  further  modified  the  procedure  by  removing  a 
diamond  or  rhomboid  section  of  skin,  long  axis  vertical,  from  the 
center  of  the  nose,  undermining  the  edge  for  some  distance,  laterally, 


^  Darstellungen,  etc.,  6,  1S41. 

2  Trait.  Comp.  d'ojjh.,  vol.  i,  p.  180. 

'  Epicanthus  und  seine  Beliandlunsj;,  Arch.  f.  i\\\\i. 


Orenh.   1 1  r,  S.   SQ. 


EPICAXTIIUS  237 

closing  with  a  number  of  fine  interrupted   sutures  and   reinforcing 
with  strips  of  gauze  and  collodion  (Fig.   108). 

Arlt^  excised  the  two  semilunar  pieces  of  integument  comprising 
the  greater  portion  of  the  epicanthal  folds  themselves,  and  in  ex- 
treme cases  a  median  ellipse  from  the  nose  also.  This  is  known 
as  lateral  rhinorraphy.  The  sutured  wounds  presented  something 
the  form  of  an  X  (Fig.  109). 


Fig.  109. — Arlt's  lateral  rhinorraphy. 

The  use  of  silver  pins,  as  in  the  Von  Amnion  operation,  is  apt  to 
leave  an  ugly  scar,  as  also  are  de  Wecker's  large  needles  and  thread. 
Knapp's  small  needles  and  thread,  with  the  auxilliary  collodion 
strips,  is  a  decided  improvement  in  this  particular.  V.  Arlt's 
method  is  also  a  good  one,  and  for  it  Knapp's  small  sutures  and 
collodion  may  be  utilized.  The  extra  scar  is  hidden  by  the  specta- 
cles which  the  subjects  of  epicanthus  usually  require. 

Later,  and  improved  surgical  measures  for  dealing  with  epi- 
canthus are  those  of  Rogman  {Archiv.  d'opht.,  t.  XVHI,  p.  453)  and 
E.  Berger  (Ann.  d'ocuL,  June,  1904)  or  Wicherkiewicz-Berger. 

Method  of  Rogman.— Midway  of  the  epicanthal  fold  and  on  a 
line  with  the  inner  angle  of  the  eye,  begin  two  incisions;  these  are 

1  Graefe-Saemisch,  iii,  S.  443. 


228 


OPERATIONS    UPON    THE    LIDS 


carried  upward,  converging,  till  they  meet,  thus  forming  an  inverted 
V  (Fig.  no, right  eye).  Then,  the  incision  nearer  the  eye  is  prolonged 
downward,  to  form  one  member  of  an  upright  V,  of  the  same  dimen- 
sions as  the  inverted  one.  Its  apex  is  on  the  crest  of  the  fold,  and  the 
other  member  is  represented  by  an  incision  that  is  carried  upward 
and  inward  on  the  ocular  face  of  the  fold,  to  end  on  a  level  with  the 
inner  angle  of  the  eye.  Thus  two  flaps  of  skin  are  outlined  whose 
length,  and  whose  breadth  of  base,  will  depend  upon  the  size  of  the 
epicanthal  folds.     The  flaps  are  dissected  free,  cut  off  at  their  bases, 


Fig.  no. — Right  eye,  method  of  Rogman.     Left  eye,  method  of  E.  Berger  or 
Wicherkiewicz. 


the  integument  of  the  fold  is  undermined,  and  the  two  triangular 
defects  are  closed  by  sliding  the  skin  and  suturing. 

Method  of  Wicherkiewicz-Berger. — Here  the  portion  of 
excised  skin  takes  the  form  of  the  head  of  a  dart,  or  arrow  (Fig.  no, 
left  eye).  It  is  outlined  in  the  centre  of  the  epicanthal  fold,  beginning 
at  a  point  on  the  side  of  the  nose,  and  on  a  level  with  the  inner  can- 
thus.  From  here  two  incisions  depart,  diverging,  passing  outward, 
and  extending  almost  to  the  crest  of  the  fold.  From  their  extremities 
two  other,  shorter,  incisions  start,  converging,  also  to  meet  on  a  line 
with  the  inner  canthus.  The  enclosed  integument  is  removed  by 
dissection,  and  its  size  is  regulated  by  the  degree  of  effect  re(]uired 
for  tile  obliteration  of  the  epicanlhus.     Lastlv,  the  skin  of  the  fold  is 


i;pi(A\Tiirs  229 

undermined,  and  the  defec  I  is  closed  by  slidin.i^  the  ponl  of  skin  into 
the  angle  opposite,  and  ihrre  fixin<^  it  with  sutures. 

The  author  suggests  trying  the  omission  of  the  rliinorraj)hy  and. 
in  lieu  thereof,  the  injection  of  paralTin,  to  l)uild  uj)  the  bridge  of  the 
nose,  which  in  these  cases  is  Hal,  and  careful  [\]m\  studied  rocction 
of  the  epicanthal  folds,  free  undermining  of  the  cut  edges,  fine,  in- 
terru[)ted  sutures,  and  the  support  of  gauze,  wet  with  llexible  col- 
lodion. Of  course,  every  precaution  must  be  taken  to  keep  this 
collodion  from  entering  the  palpebral  fissures.  None  but  those  with 
skill  and  experience  in  the  prosthetic  employment  of  parafhn  should 
attempt  such  use  of  it  on  account  of  the  dangers  from  paralTm 
embolism.  It  must  be  remembered,  too,  that  the  mass  of  paraffin 
that  is  put  into  the  tissues  has  a  treacherous  way  of  sometimes 
changing  its  form  and  its  location.  The  results  of  epicanthus 
operations  are  seldom  beautiful,  whatever  the  method,  because  of 
the  usual  accompanying  congenital  anomalies,  such  as  ptosis, 
microphthalmos,  sc[uint,  etc. 


CHAPTER  XL 
OPERATIONS  FOR  PTOSIS. 

The  original  term  for  falling  down  of  the  upper  lid  was  hlepharop- 
tosis,  which,  although  more  expressive  as  to  the  actual  import  of  the 
word,  has  quite  properly  been  superseded  by  the  abreviation 
ptosis.  This  affection  may  be  either  congenital  or  acquired.  Con- 
genital ptosis  is  not  uncommon,  and,  in  a  large  proportion  of  the 
cases,  it  is  bilateral.  It  is  often  associated  with  epicanthus,  microph- 
thalmus,  squint,  and  other  connate  defects.  Acquired  ptosis  is,  in 
most  instances,  paralytic;  that  is,  it  is  the  result  of  paralysis  of  the 
levator  from  disease  or  from  traumatism.  Distinctive  forms  of 
ptosis  are  ptosis  senilis,  from  slow  progressive  atrophy  of  the  levator; 
ptosis  adiposa,  and  ptosis  elephantiastic,  or  cutaneous  ptosis,  from 
redundance  and  relaxation  of  the  lid  tissues;  ptosis  trachomatosa , 
from  the  combined  effects  of  the  characteristic  infiltration,  the 
blepharospasm  and  the  ensuing  shrinkage  of  the  conjunctival  sac 
from  trachoma;  and  ptosis  hysterica,  or  pseudo-ptosis,  from  voluntary 
or  spastic  contraction  of  the  orbicularis.  The  dropping  of  the  lid 
is  also  distinguished  as  partial  or  complete. 

Whether  congenital  or  acquired,  the  vast  majority  of  cases  are 
fit  subjects  for  surgical  treatment.  This  is  divided  into  palliative 
or  provisional,  and  curative  or  definitive.  The  first  consists  in  the 
application  to  the  lid  of  collodionized  bands  or  strips  of  adhesive 
plaster,  the  insertion  of  restraining  sutures  beneath  the  skin,  and  the 
wearing  of  specially  designed  preventive  spectacles,  or  artificial 
spring  supports,  of  thin  metal  or  other  material,  affixed  to  the  lid 
borders,  to  act  as  antagonists  of  the  orbicularis.  These  temporary 
measures  are  seldom  resorted  to;  for,  when  intervention  of  any  kind 
is  called  for,  an  operation  that  will  give  permanent  relief  is  de- 
manded, or  operative  treatment. 

It  is  rather  singular  to  note  how  liule  attention  was  paid  to  ptosis 
in  early  times — surgically,  at  least,  l^y  the  ancients,  the  affection 
was,  in  great  measure,  confused  with  entropion  and  trichiasis;  and 
about  the  only  operation  adopted  with  reference  to  it  was  the  ex- 
cision of  a  horizontal  ellipse  of  skin  from  midway  of  the  fallen  lid, 
and   varying  in  size  with  the  (k\grcc  of  the  ptosis.     No  material 

230 


f'LASSIFICATION    OK    METHODS  23I 

change  was  made  in  the  status  of  such  surgery  until  i<S8o.  True, 
von  Graefe^  had  made  an  attem])t  to  im])rove  it.  He  incised  the  skin 
the  entire  length  of  the  Hd,  opened  wide  the  cut,  and  resected  a  strip 
of  the  orbicularis,  about  one  centimeter  in  width  and  as  long  as  the 
incision.  The  wound  was  closed  without  excision  of  skin.  The 
idea  was  to  cause  subcutaneous  shortening  of  the  lid,  together  wilii 
the  w^eakening  of  the  power  of  the  opponent  of  the  levator,  viz.,  the 
orbicularis.  Mention  may  also  be  made  of  the  curious  tentatives 
employed  by  Denouvilliers  and  Gossclin,  whereby  they  hoped  to 
make  a  lasting  perforation  in  the  fallen  lid  to  serve  as  a  window- 
through  wdiich  the  patient  could  sec.  During  the  last  twenty-five 
years,  however,  ophthalmic  surgeons  have  been  tremendously  pro- 
lific in  the  operative  measure  they  have  contrived  for  the  correction 
of  this  defect.  So  numerous  are  they  that  to  attempt  a  description 
of  each  is  out  of  the  question.  We  must,  therefore,  content  our- 
selves w^ith  detailing  only  a  few^  of  them.  Most  of  the  measures  in 
question  have  for  object  either 

1.  The  linking  of  the  lid  directly  to  the  frontalis  muscle. 

2.  The  advancement  of  the  natural  elevators  of  the  lid,  or 

3.  The  inosculation  of  the  skeleton  of  the  lid  wnth  the  superior 
rectus  muscle. 

Moreover,  each  contemplates,  or  affects,  a  certain  amount  of 
shortening  of  the  entire  lid. 

The  conspicuous  manner  in  which  the  frontalis  offers  itself  as 
nature's  substitute  for  the  crippled  levator  in  ptosis  early  led  surgeons 
to  think  of  means  for  giving  this  muscle  greater  purchase  over  the 
fallen  lid.  Hunt  (1838)  and  later  Morand,  thought  to  achieve  this 
through  more  or  less  ingenious  sliding  or  transposing,  of  skin  flaps 
about  lid  and  brow.  Others  went  deeper,  with  the  idea  of  making 
an  actual  anastomosis  between  the  frontalis  and  the  orbicularis. 
\^autrin,  for  example,  brought  down  a  fragment  of  the  frontal  muscle 
and  attached  it  to  the  lid,  while  Darier  tried  engrafting  a  strip  of 
the  orbicularis  upon  the  frontalis. 

The  notion  of  putting  the  upper  lid  in  closer  touch  with  the  frontal 
muscle  by  means  of  deep  cicatricial  bands  was  first  conceived  by 
Dransart.-  The  union  Avas  accomplished  by  means  of  sutures 
connecting  the  lid  anrl  the  superciliary  region,  and  the  method  has 
been  called  deep  palpehro-frontal  ligature. 

1  Archiv.  f.  Oph.,  Bd.  ix,  2,  S.  57. 

2  Annals  d'oculist,  vol.  Ixxxiv,  p.  88,  1880. 


232 


OPERATIONS    FOR    PTOSIS 


Dransart  employed  buried,  absorbable  sutures  (Fig.  iii).  He 
made  an  incision  along  the  upper  border  of  the  tarsus,  opened  wide 
the  wound,  particularly  above,  where  he  carried  the  loosening  up  as 
far  as  the  supercilia.  A  needle,  armed  with  catgut,  was  made  to 
transverse  the  tarsus,  beginning  about  its  middle,  passing  upward 
deep  into  its  substance,  then  through  the  fibres  of  the  orbicularis  to 
a  point  just  below  the  supercilia.  Here  it  is  turned  and  passed 
back  through  the  same  structures,  alongside  its  iirst  course,  and  was 
brought  out  on  a  level  with  its  entrance.  Two  other  sutures  were 
introduced  in  the  same  way,  parallel  with  the  first,  and  all  three 


Fig.  III. — Dransart. 


Fig.  112. — Pagenstccher. 


tied.  The  degree  of  tightening  could  be  governed  by  that  of  the 
ptosis,  but  the  chief  merit  of  the  method  was  assumed  to  lie  in  the 
three  cicatricial  bands  or  cords  running  from  tarsus  to  frontalis. 
The  skin  incision  was  closed  and  the  buried  sutures  were  left  to  their 
fate. 

H.  Pagenstecher^  modified  Dransart's  procedure  (Fig.  112).  The 
operation  consisted,  merely,  in  the  introduction  of  tw^o  subcutaneous, 
double-armed  sutures,  running  from  near  the  free  border  to  a  point 
above  the  supercilia,  where  they  were  tied  in  bowknots  over  sections 
of  rubber  tubing.  These  were  left  in  place  to  suppurate,  and  were 
gradually  tightened  or  drawn  u])  from  time  to  time,  and  made  to  cut 
their  way  out.  No  incision  was  made,  the  originator  relying  for 
his  result  upon  the  effect  obtained  by  the  cicatricial  tracts  unit- 
ing lid  and  frontalis  caused  by  the  sutures  cutting  thnnigh  the 
tissues. 

De  Wecker^  went  still  further,  and  modihed  this  operation  by 
removing  a  long  oval  of  the  skin  and  underlying  muscle,  whose  lower 


'  Internal.  Conjijrcss  of  C)])litlialmol().i,'v,  London,  iSSi 
2  Aniial.  (I'nrulist,  I.  88,  j).  29,   1882."  " 


METHODS    OF    IIF.SS    AM)    MULES  233 

edi^c  was  four  or  li\X'  millimeters  from  iht-  free  border.      iFi'k-  'I3-) 
For  the  rest,  he  proceeded  as  did  Pagenstecher. 

Hess^  modiikd  the  Pagenstecher-De  Wecker  ])rocedures  thus: 
Incision  the  whole  length  of  the  previously  shaved  supercilia, 
through  skin  and  subcutaneous  connective  tissue  (Fig.  114).  Dis- 
section downward,  between  integument  and  orbicularis,  to  near  the 
ciliary  border.  Insertion  of  three  double-armed  sutures  about  mid- 
way of  the  loosened  flap,  which  are  carried  up  beneath  the  skin, 
brought  out  at  a  point  on  the  brow  two  centimeters  above  the 
primary  incision,  and  knotted  over  sections  of  drain   tube.     The 


Fig.  113.— DeWecker.  FiG.  114.— Hess. 


upper  half  of  the  llap  is  by  this  means  thrown  into  a  horizontal  fold, 
the  size  or  height  of  which  corresponds  to  the  degree  of  effect,  the 
loops  of  thread  causing  a  depression  that  simulates  the  normal 
sulcus.     The  sutures  are  removefl  at  the  end  of  the  tenth  day. 

It  would  seem  that  this  measure  is  likely  to  i)roduce  rather  undue 
shortening  of  the  lid. 

A  phase  of  the  Dransart  method  is  that  of  Mules-  (Fig.  115).  In- 
stead of  silk  or  catgut  sutures  he  employs  gold  or  silver  wire,  which 
is  put  in  after  the  following  manner:  Incision  along  the  free  border 
of  the  lid,  as  if  for  intermarginal  graft,  though  not  so  deep.  One  of 
corresponding  length  in  the  middle  of  the  shaved  suj)ercilia.  Two 
sutures  of  line  gold  or  silver  wire,  each  armed  with  two  needles,  are 
introduced  at  the  bottom  of  the  marginal  incision,  carried  up  under 
the  orbicularis  to  emerge  from  beneath  the  upper  lip  of  the  brow- 
incision,  so  as  to  include  the  frontalis.  The  tracts  of  each  pair 
of  needles  are  six  to  eight  millimeters  apart.  The  lid  having  been 
drawn  up  sufficiently,  the  sutures  are  tied.     The  cut  in  the  eyebrow 

1  Oph.  Society  of  Heidelberg,  28th  Session,  Au<:j.,  1803. 

2  Trans.  Oph.' Society  of  the  United  Kingdom,  vol.  xviii,  p.  227. 


234 


OPERATIONS    FOR    PTOSIS 


is  closed  wiih  line  silk  sutures;  that  in  the  border  is  left  to  close  of 
itself. 

Objections  that  have  been  offered  to  this  procedure  are  liability 
of  the  wire,  after  a  time,  to  break  or  to  be  expelled,  and  injury 
to  the  hair  follicles  of  the  cilia.  To  obviate  these  features,  Bishop,  ^ 
of  Cambridge,  proposed  substituting  for  the  wire  a  fine  wove  chain 
of  gold.  A  single  strand  of  this  is  threaded  into  a  four-inch  abdomi- 
nal needle.  No  incision  is  made  (Fig.  ii6).  The  needle  is  first  in- 
serted above  the  supercilia,  a  little  to  the  nasal  side,  passed  down 
beneath  the  orbicularis,  close  to  the  tarso-orbital  fascia  and  tarsus, 
brought  out  near  the  cilia,  reinserted  at  the  point  of  exit,  carried 


Fig.  ii6. — Bishop. 

horizontally  along  near  the  free  border,  brought  out  external  to  the 
median  line,  reinserted,  passed  upward,  parallel  with  its  downward 
course,  to  emerge  on  a  level  with  the  point  of  first  entrance.  After 
drawing  up  the  lid  the  requisite  degree,  the  needle  is  put  deep  into  the 
frontalis  where  it  came  out  last,  plowed  horizontally  along,  and  iinally 
brought  out  where  it  first  entered.  The  ends  are  cut  off  and  buried 
beneath  the  skin. 

Wilder2  makes  a  similar  operation  to  that  of  Dransart,  though  with 
some  important  differences  and  improvements  (Fig.  117).  The 
primary  incision  extends  for  three  and  one-half  centimeters  along  the 
median  line  of  the  shaved  eyebrow  down  to  the  periosteum  of  the 
orbital  rim.  The  lower  lip  is  undermined  and  retracted  until  the 
tarsus  is  exposed.  Two  double-armed  silk  or  catgut  sutures  are  put 
into  the  tarsus,  one  on  cither  side  of  its  center,  and  each  pair  of 
needles  is  carried  upward  a  few  millimeters  apart,  but  in  their 
course,  instead  of  traversing  the  orbicularis,  as  Dransart's  do.  they 
are  quilted  througii  the  tarso-orbital  fascia  and  brought  out  so  as  to 

1  British  Medical    lounial,  Scjit.  26,   1003. 

2  Annals,  of  Oi-htlialmohiKy,  vol.  vii,  No.  i,  1898. 


METHOD    OF    PAN AS 


235 


include  the  muscular  and  connective  tissue  just  beneath  the  ui)j)er  lip 
of  the  brow  incision.  The  sutures  are  (h-awn  up  to  the  degree  de- 
sired for  the  elevation  of  the  lid  and  tied.  The  sutures,  or  ligatures, 
are  left  to  be  absorbed  or  encapsuled.  Thus,  not  only  are  there  two 
cicatricial  cords  connecting  tarsus  and  frontalis,  but  there  is  also  a 
shortening  of  the  septum  orbitale  which,  in  this  instance,  serves  as 
an  advancement  of  the  tendon  of 
the  levator  (now  really  the  frontalis). 
Panas^  is  the  author  of  what  has 
been  one  of  the  most  ])opular  opera- 
tive modes  for  the  relief  of  ptosis. 
This  master  in  surgery,  recognizing 
the  uncertainty  of  obtaining  the  de- 
sired cicatricial  result  after  the  mere 

suture  operation,  devised  a  more  strictly  surgical  method,  the 
essential  feature  of  which  is,  according  to  its  author,  the  direct 
autoplastic  fixation  of  the  lid  icith  the  orbitofrontal  muscle  (Figs. 
118  and  119).  Panas  called  the  operation  blepharopexy  and  it 
may  be  described  as  follows :  A  lid  spatula  is  put  into  the  upper 
conjunctival  cul-de-sac.  A  horizontal  incision  is  made  midway  be- 
tween the  eyebrow  and  free  border  of  the  upj)cr  lid  through  skin 


Fig. 


Panas. 


and  orbicularis  down  to  the  tarso-orbital  fascia.  From  this  in- 
cision branch  two  others,  including  skin  only,  one  on  either  side, 
vertically,  or  slightly  inclining  outward,  till  opposite  the  upper  bor- 
der of  the  tarsus,  when  they  are  given  a  direction  yet  more  divergent, 
which,  in  terminating — the  inner  one  near  the  punctum,  the  outer 
1  Maladies  des  Yeux,  T.xi.,  p.  140,  1894. 


236  OPERATIONS    FOR    PTOSIS 

close  to  the  external  commissure — is  almost  parallel  with  the  ends 
of  the  lirst  incision.  The  three  i)oints  or  tiaps  thus  outlined  are 
dissected  up.  A  cut  is  then  made  along  almost  the  entire  midline 
of  the  shaved  supercilia,  comprising  skin  and  the  thick  layer  of 
muscular  fibres  formed  by  the  interlacing  of  the  orbicularis  and 
the  frontalis.  The  bridge  of  integument  between  the  two  hori- 
zontal incisions,  is  tunneled  through  with  a  bistoury.  The  middle 
flap  overlying  the  tarsus  is  pushed  up  through  the  tunnel  and 
sutured  to  the  su])erior  lip  of  the  upper  incision  by  three  stitches. 
Superficial  sutures  are  put  in  to  close  the  remaining  gaps. 

The  degree  of  efi'ect  is  regulated  by  placing  the  primary  incision 
higher  or  lower,  as  the  case  may  be,  and  by  the  extent  to  which  the 
buried  flap  is  drawn  up.  If  it  is  observed,  in  drawing  up  the  flap, 
that  there  is  a  tendency  to  ectropion  before  the  sutures  are  tied,  two 
others  are  put  into  the  tarso-orbital  fascia,  one  on  either  side  of  the 
middle  flap,  but  not  into  the  skin.  These  also  are  passed  through 
the  tunnel  and  united  to  the  upper  lip  of  the  brow  incision  near  its 
extremities.  These  last  are  supposed  to  lift  the  paralyzed  lid  in  the 
natural  manner,  i.e.,  by  giving  to  it  the  movement  of  a  rotary  hinge, 
upward  and  backward,  revolving  on  an  imaginary  axis,  which 
passes  through  the  two  commissures. 

The  procedure,  while  successful  to  a  degree,  has  certain  serious 
drawbacks.  The  considerable  disturbance  of  the  normal  relation 
of  the  parts,  the  obliteration  of  the  physiologic  sulcus,  and  the  sub- 
stitution for  it  of  an  inverted  fold,  the  covering  up  of  an  epithelial 
surface  by  a  raw  one,  and  the  fact  that  the  effect,  after  all,  is  obtained 
by  what  amounts  to  pronounced  resection  of  the  skin,  are  all  ob- 
jectionable features. 

Hunt-Tansley  Operation.— Devised  by  Hunt  and  modified  by 
the  late  J.  O.  Tansley,  of  New  York.  It  belongs  in  the  same  group 
with  tiie  Panas  operation,  and  is  mentioned  here  because  it  has  at- 
tained considerable  popularity  in  some  parts  of  the  United  States, 
particularly  in  the  East.  Fig.  120  shows  the  lines  of  incision.  Two 
horizontal,  parallel  incisions,  each  one-half  inch  long,  are  made 
through  the  skin,  one  just  below  and  the  other  just  above  the  middle 
of  the  eyel)row,  and  the  two  are  joined  by  tunneling  under.  From 
the  lower  one  two  parallel  incisions  are  carrit'd  downward,  one  (|uar- 
ter  inch  a])art,  to  within  one-eightli  inch  of  the  cilia.  The  vertical 
strip  of  skin  thusouthned  is  dissected  loose  down  to  its  base,  a  dou- 
ble armed  suture  is  i)Ut  into  its  free  end,  and  it  is  wrai)ped  round  a 


IIUNT-TANSLKY    MF.TIIOD 


2.^7 


cylinder  of  gauze  or  cotton  wet  with   warm  normal  salt  solution. 

From  the  attached  extremity  of  this  llaj)  two  cuts  are  made,  one 

outward,  the  other  inward,  parallel  with  the  free  border  of  the  upper 

lid,  to  end  at  points   directly   above  the   canthi — through  skin  and 

orbicularis.      The    can  thai 

ends  of   these  cuts  are  then 

joined   ])y   an   incision  made 

along  the  sulcus  which  corre- 

s]wnds  to  the  upper  border  of 

the  tarsus.     This  also  includes 

skin    and    orbicularis.      The 

two  triangles  of  skin  and  the 

crescent  of  muscle  so  formed 

are  dissected  out,  leaving  the 

tarsus    exposed.      Now,    the 

needles  attached  to  tlie  suture 

in     the   tongue   of    skin   are 


^^D^. 


-Hunt-Tanslev. 


passed  upward  through  the  tunnel  beneath  the  eyebrow,  and  the 
operation  is  completed  by  stitches,  as  shown  in  Fig.  121. 

One  of  the  latest  phases  of  the  Vautrin-Darier  idea,  referred  to 
further  back,  is  the  method  of  Frccland  Fergus, 1  of  Glasgow.     By 

this  measure  a  strip  of  the  oc- 
cipito-frontalis  is,  as  it  were, 
dovetailed  into  the  affected 
lid.  It  is  briefly  thus:  Inci- 
sion the  whole  length  of  the 
j  eyebrow  down  to  the  tendon 
of  the  frontalis.  Dissection 
of  the  skin,  upward  for  a 
distance  of  two  inches  and 
downward  almost  to  the  free 
border  of  the  lid.  The  upper 
lip  of  the  wound  is  strongly 
retracted  to  expose  the  fron- 
talis, from  which  is  formed  a  llap  or  tongue  three-quarters  of  an 
inch  wide  and  two  inches  long.  Through  this,  near  its  lower  or 
free  end,  are  passed  from  below  two  double-armed  sutures.  These 
are  carried  down  to  the  bottom  of  the  pocket  made  in  the  lid, 
brought  out,  and  tied  on  the  skin  just  above  the  cilia.  The  brow 
incision  is  closed  by  interrupted  sutures. 

1  Brit.  Med.  Journal,  March,   1901. 


121. — Hunt-Tanslev. 


238  OPERATIONS    FOR    PTOSIS 

This  method  certainly  affords  a  means  of  directly  coupling  the 
frontal  muscle  and  the  lid.  Whatever  is  gained,  however,  must  be 
through  the  enhanced  power  of  the  muscle,  as  a  whole,  to  raise  the 
lid.  For  it  is  not  to  be  presumed  that  the  transplanted  tongue  will 
be  endowed  with  separate  or  special  c|ualities  of  contraction  in  the 
vicarious  office  thus  thrust  upon  it;  nor  that  the  tongue  will  be  free 
to  slide  up  and  down  Hke  a  muscle  in  its  sheath.  The  best  that  can 
occur  is  that  the  lid  will  be  held  up  by  a  more  or  less  rigid  band  ex- 
tending down  from  the  forehead.  And  one  can  readily  fancy 
how  such  a  measure  could  leave  the  motility  of  the  tissues  about  the 
brow  more  restricted  than  they  had  previously  been. 

2.  Advancement,  or  shortening  the  levator,  by  making  a 
fold  therein,  was  first  suggested  by  Bowman  in  the  first  volume  of 
Moorfield's  Hospital  Reports,  and 
first  practised  by  Eversbusch,^  of 
Munich  (Fig.  122).  Under  general 
anesthesia,  the  plate  of  Snellen's 
forceps  is  placed  as  high  as  possible 
beneath  the  upper  lid  and  the  clamp 
set.  A  horizontal  incision  is  made, 
Fig.  122.— Evcrsbusch.  halfway  between  the  brow    and  the 

ciliary  border,  down  to  the  fascia,  the 
latter  exposed  by  separating  the  lips,  a  vertical  fold,  two  and  one- 
half  millimeters  wide,  is  picked  up  in  the  center  of  the  so-called 
tendon,  a  small,  double-armed  thread  is  entered  into  each  side  of 
the  fold,  carried  downward  between  tarsus  and  orbicularis,  and  the 
needles  brought  out  two  or  three  millimeters  apart  at  the  free 
border.  Two  other  sutures  are  similarly  placed,  one  at  either  side. 
The  primary  incision  is  sutured  and,  lastly,  the  three  pairs  of  thread 
ends,  projecting  from  the  edge  of  the  lid,  are  tied  over  small  sections 
of  rubber  tubing.     Both  eyes  are  bandaged. 

Snellen, 2  of  Utrecht,  is  credited  with  at  least  two  methods  to 
shorten  the  levator  tendon : 

I.  By  Resection. — After  exposing  the  fascia  in  the  usual  way, 
by  an  incision  parallel  with  the  upper  lid  border,  a  cut  was  made 
transversely  through  it  (Fig.  123).     Two  or  three  catgut  sutures 

1  Zur  Operation  der  congenitalcn  Blepharoptosis.  Klin.  Monatsbl.  f. 
Augenh.,  Bd.  xxi,  S.  100,  1883. 

2  Report  of  the  German  Oph.  Society  at  Heidelberg,  1883. 


SNELLEN  S    METHODS  239 

were  passed  through  the  upper  edge  of  the  tarsus  from  the  front; 
the  cut  end  of  the  tendon  was  lifted,  the  sutures  passed  through  it, 
high  up,  from  the  back,  a  portion  was  resected  commensurate  with 
the  amount  of  shortening  desired,  the  threads  were  tied  and  the  skin 
wound  closed.  Fuchs  makes  a  resection  somewhat  similar  to  the 
above. 

2.  By  tucking  without  any  incision,  either  of  the  skin  or  of  the 
conjunctiva,!  by  means  of  burrowing  sutures  (Fig.  124).  At  the 
center  of  the  insertion  of  the  levator  a  thread  is  made  to  pass  through 
skin,  tarsus,  and  conjunctiva.  Then,  with  the  lid  everted,  it  is 
carried    upward   between   the    conjunctiva   and   the   fascia,  again 


Fig.  123.  —Snellen,  No.  i.  FiG.  124.— Snellen,  No.  2. 

brought  out  through  the  skin,  the  latter  is  lifted,  the  needle  inserted 
at  about  the  same  point  whence  it  has  just  emerged,  passed  down 
beneath  the  integument,  and  brought  out  where  it  first  penetrated. 
Two  others  are  thus  inserted,  one  on  either  side  of  the  first,  and  their 
ends  are  knotted  over  bits  of  drainage  tubing.  Gruening,  of  New 
York,  had  already  made  practically  the  same  operation,  though 
with  the  aid  of  the  ordinary  skin  incision. 

De    la    Personne,2  Angelucci,^   and  others  have   also   modified 
the  Eversbusch  procedure. 

Method  of  Angelucci.'' — Like  the  rest  of  this  noted  specialist's 
work,  this  is  a  truly  surgical  measure.  The  object  is  here  sought 
by  shortening  the  levator  tendon  through  section  and  overlapping,  at 
the  same  time  joining  it  to  the  frontalis  (Fig.  125).  An  incision  is 
made  through  the  skin   about  one  centimeter  below,  and  parallel 

1  Trans.  Oph.  Society  of  the  United  Kingdom.     Oph.  Review,  Nov.   14, 
1889. 

2  Archiv.  d'opht.,  vol.  xxiii,  p.  497,  1903. 

3  Archiv.  di  Ottala.  p.  489,  1904- 

•>  Thirteenth  Internat.  Cong,  of  Med.,  Paris,  1900. 


240 


OPERATIONS    FOR   PTOSIS 


with,  the  eyebrow,  and  three  centimeters  in  length.  The  lower  lip 
of  the  wound  is  dissected,  and  retracted,  down  to  the  level  of  the 
upper  border  of  the  tarsus.  About  3  mm.  above  this  border  a  hori- 
zontal incision  is  made  through  the  orbicularis,  to  lay  bare  the  entire 
breadth  of  the  tendon  of  the  levator.  The  latter  is  picked  up  with 
a  strabismus  hook  and  divided  some  4  mm,  above  the  convex 
edge  of  the  tarsus.  Now,  through  the  stump  of  tendon  adherent 
to  the  tai'sus  are  passed,  from  before  backward,  two  double-armed 


Fig. 


125. — Angelucci's  operation  for 


ptosi; 


sutures  carrying  No.  2,  or  No.  3  braided  silk.  The  threads  are  then 
tightly  and  securely  tied,  on  the  posterior  face  of  the  tendon,  to  insure 
their  hold.  After  this  the  sutures  are  passed  up,  between  orbicularis 
and  tarso-orbital  fascia,  to  emerge  3  mm.  above  the  eyebrow,  where 
they  are  drawn  up  so  as  to  lift  the  lid  to  the  desired  height,  and 
tied  in  bow-knots  over  cylinders.  And  here  the  strongest  point  of 
the  procedure  is  made  apparent,  in  that  it  gives  the  operator  such  a 
range,  as  it  were,  of  control  over  the  fallen  lid.  The  skin  incision 
needs  merely  to  be  coapted — not  sutured.  If  there  chances  to  be 
present,  as  in  certain  \arieties  of  ])t()sis,  a  redundance  of  integument, 


GRUEXIXG  S    METHOD  24 1 

an  clli])sc  may  be  excised.  Al  the  end  of  a  day  or  two  the  de.i^ree  of 
ele\ati()n  of  tlie  lid  ean  he  modified  hy  j)unin,i!;  out  the  loo|)  of  the 
knot  and  ti^hteninLi;  or  loosening  the  thread  as  the  case  demands. 

Resection  of  the  tarsus  as  a  measure  for  the  cure  of  ptosis 
was  revived  by  Sir  William  Bowman,  as  an  adjunct  to  resection  of 
the  orbicularis,  as  practised  by  his  friend  von  Gracfe,  At  a  glance 
this  method  would  seem  to  stand  in  a  class  by  itself,  yet  virtually 
it  is  but  an  advancement  of  the  muscles  normally  concerned  in 
lifting  up  the  lid.  Bowman  removed  a  portion  of  the  tarsus  and 
the  contiguous  portion  of  the  orbicularis.  Galezowski  went  still 
further  and  excised  a  strij)  that  included  the  whole  thickness  of 
the  lid.  A  well-known  modification  of  the  Bowman  operation  is 
that  of  Gillet  de  Grandemont.^ 

Grucning,-  of  New  York,  has,  for  some  time,  employed,  with 
satisfactory  results,  a  modified  form  of 
De  Grandemont's  method  (Fig.  126). 
He  uses  it  for  almost  any  ^■ariety  of 
ptosis,  and  performs  it  as  follows:  An 
incision  is  made  through  skin  and 
orbicularis  muscle,  parallel  with,  and 
4  mm.  from,  the  free  border.  Skin  and 
muscle  are  dissected   up  and  retracted.  pig  126.— Gruening. 

A  portion  of  the  bared  tarsus,  com- 
prising its  whole  width,  from  inner  to  outer  canthus,  and  the  whole 
thickness,  including  the  adherent  conjunctiva,  is  cut  out.  The 
vertical  diameter  of  the  excised  strip  varies  with  the  degree  of  ptosis, 
though  it  is  always  wider  in  the  middle,  wdiere  it  may  measure  7  mm., 
tapering  almost  to  a  point  at  either  extremity.  The  tarsal  wound  is 
closed  by  three  double-armed  sutures.  One  needle  is  passed 
horizontally  through  the  tarso-orbital  fascia,  then  both  needles  are 
passed  downward,  through  the  remnant  of  tarsus,  and  brought 
out  at  its  free  border,  behind  the  lashes,  where  the  suture  is  knotted. 
Thus  the  lips  of  the  tarsal  wound  are  brought  into  apposition,  and 
the  lashes  are  given  a  horizontal  direction.  The  skin  opening  needs 
no  sutures, 

3.  Joining  the  Tarsus  with  the  Superior  Rectus.— In  cases 
of  ptosis   not   com])licated    with   ])aralysis   of   the   sui)erior  rectus, 

1  Bull,  et  mem.  de  la  soc,  Franc,  d'n])!!!.,  1891,  p.  80. 

2  New  York  Eye  and  Kar  Infirmary  Reports,  1904. 

16 


242 


OPERATIONS    FOR    PTOSIS 


the  late  Dr.  ParinaucU  (Fig.  127),  after  having  everted  the  upper 
lid,  made  a  horizontal  incision  one  and  one-half  centimeters  long,  in- 
cluding the  conjunctiva,  and  the  upper  border  of  the  tarsus  at  its 
middle;  seized  the  conjunctiva  with  fixation  forceps  near  the  upper 
corneal  limbus,  and  rotated  the  globe  far  downward;  opened  up  the 
conjunctival  incision,  and  exposed  the  tendon  of  the  rectus,  raised  it 
with  forceps,  passed  a  double-armed  suture  beneath  it,  including  its 
aponeurosis.  Then  each  of  the  needles  was  passed  upward,  through 
the  adjacent  conjunctiva,  thence  through  the  levator  tendon,  down- 
ward between  tarsus  and  skin,  and  brought  out,  seven  millimeters 


Fig.  127. — Parinaud. 


Fig.  128. — ^Motais. 


apart,  at  the  free  border.     They  were  here  tied  over  some  soft 

substance,  and  taken  out  after  four  to  six  days. 

Motais,-  of  Angers,  has  given  an  ingenious  and  highly  approved 

ptosis    operation,    which    embodies    the    Parinaud    principle: — a 

meridional  incision  of  the  conjunctiva,  beginning  over  the  center 

of  the  insertion  of  the  tendon  of  the  superior  rectus,  or  about  7 

mm.  from  the  upper  corneal  limbus — is  extended  through  the  retro- 

tarsal  folds,  to  end  at  the  convex  edge  of  the  tarsus  (Fig.  128).    This 

is  opened  and  retracted,  so  as  to  plainly  reveal  the  tendon,  which  is 

then  lifted  upon  a  strabismus  hook.     The  hook  is  worked  back  and 

forth  in  such  a  manner  as  to  loosen  the  tendon  from  its  surroundings. 

A  fme,  but  strong  braided  suture,  armed  witli  two  curved  needles, 

is  passed  in  and  out  through  the  tendon  near  its  insertion,  so  as  to 

include  its  middle  third.     To  give  the  thread  a  solid  hold,  it  has  been 

suggested  that  it  be  at  once  lied.     This,  liowcNcr,  is  apl  to  c()m])licate 

^Annd'oc,  1897,  1.  cxvii,  ]>.  '-'• 

2  Bull,  et  m^ni.  de  la  soc,  d'opht,  de  Paris,  Nov.,  iS()S. 


ii'i;k.\  I'lox 


!43 


Fig.  i2g. — Motais. 


matters  in  rem()\inii;  it.  'I'o  ])i\'WiU  twisting'  of  the  lon.^uc  each 
thread,  with  its  needle,  is  kept,  or  held  by  an  aid.  at  the  corre- 
sponding canthus  till  after  the  next  ste]).  With  knife  and  line  blunt- 
pointed  scissors,  a  tongue  is  formed  of  the  portion  embraced  by 
the  thread,  its  free  extremity  cut  Hush  with  the  sclera,  and  the  other 
left  at  the  union  of  the  muscle  fibres;  i.e., 
it  extends  the  entire  length  of  the  tendon. 
It  must  be  seen  to  that  the  thread  is  firmly 
fixed  in  the  end  of  the  tongue.  If  there  be 
any  doubt  on  this  point,  the  tongue  is 
folded  u})on  itself  and  the  suture  again 
I)assed  through.  The  surgeon  places  the 
tip  of  his  index  behind  the  inverted  lid  as 
a  guide,  and,  with  the  scissors,  makes  a 
pocket  between  the  anterior  surface  of 
the  tarsus  and  the  fascia  of  the  orbicularis. 
This  pocket  is  wide  enough  to  receive  the 
tongue  and  reaches  almost  to  the  border 
of  the  lid.  The  needles  are  passed  into  the  pocket,  through  at 
its  bottom,  to  emerge  on  the  skin  surface  of  the  lid,  near  the 
cilia,  about  4  mm.  apart,  and  are  tied  over  a  roll  of  antiseptic  gauze 
(Fig.  129).     It  greatly  facilitates  the  entering  of  the  needles  into  the 

depths  of  the  pocket  if  an 
assistant  will  insert  an  in- 
strument, like  the  Ik-ard 
blunt  dissector,  in  the 
pocket  and  pry  it  open  while 
the  needles  are  being  put 
through.  The  conjunc- 
tival opening  is  closed  with 
the  sutures.  It  were  well 
to  have  these  of  catgut 
and  leave  them  to  be  ab- 
sorbed, thereby  obviating 
any  disturbance  of  the  lid 
at  the  end  of  two  of  three 
days.  The  thread  attached  to  the  tendon  is  removed  at  the  end  of 
5  days  to  a  week. 

Motais'  procedure  is  founded  upon  the  synergy  of  action  existing 
between  the  sui)erior  rectus  and  the  levator.     It  follows,  theoretically, 


244 


OPERATIONS    FOR    PTOSIS 


that,  as  a  result  of  ihc  cngrafled  tendon,  natural  movements  are 
imparted  to  the  lid.  In  other  words,  that  in  looking  up,  for  example, 
the  lid  does  not  lag  behind.  ^ 

For  a  number  of  years  past  I  have  practised,  with  most  gratify- 
ing results,  a  method  that  combines  the  principles  of  the  Anagnos- 
takis-Hotz  entropion  operation,  the  tucking  of  the  levator  tendon 
of  Eversbusch,  and  a  little  of  the  suture  arrangement  of  Pagenstecher^ 
(Figs.  130  and  131).  A  lid  horn  is  put  beneath  the  upper  lid.  An 
incision  is  made  along  the  sulcus,  rather  in  its  upper  slope  than  exactly 
in  its  bottom,  through  skin  and  muscle,  and  extending  the  whole  length 
of  the  tarsus.     The  divided  fibres  of  the  orbicularis  are  undermined, 

both  above  and  below,  exposing  the 
tarsus  and  its  suspensory  ligament. 
Four  curved,  one-inch-long  needles, 
carrying  two  sutures  (i.e.,  double- 
armed)  of  No.  3  braided  silk,  boiled 
in  vaselin-paraffin,  are  in  readiness. 
Each  needle  is  passed  through  the 
lower  flap  near  its  edge,  from 
within  outward,  then  through  a 
horizontal  fold  of  the  tarso-orbital 
fascia — really  the  tendon  of  the 
levator — picked  up  by  broad- jawed 
fixation  forceps,  thence  upward, 
quilting,  or,  as  Wilder  says, 
"gathering"  the  septum  orbitale, 
and  brought  out  well  above  the  supercilia. 

A  handy  way  of  picking  up  the  deep  fascia  at  any  chosen  point, 
is  to  first  dig  the  point  of  the  needle  in  somewhat,  in  order  to  lift  the 
tissue,  then  grasp  it,  in  the  horizontal  sense,  with  the  jaws  of  the 
forceps.  The  threads  are  so  spaced  that  the  loop  left  lying  inside 
the  lower  flap  is  about  six  to  eight  millimeters  long,  and  its  middle 
marks  the  junction  of  the  middle  and  end  thirds  of  the  tarsus.  At 
first  1  i)Ut  the  needle  through  the  lower  flap  of  skin  and  muscle 
from  the  cutaneous  surface,  but  soon  found  that  this  tended  to  fold 
the  fla])  horizontally,  and  to  turn  its  edge  outward. 

The  manner  of  tying  the  sutures  is  important.     One  ])air  of 
thread  ends  is  held  between  the  left  thumb  and  index,  while,  by 
1  For  further  remarks  on  the   Motais  operation  sec  SitiiiDiary  at  end  of 
chapter. 

M)i.h.   Record. 


-Beard's  method  fur  ptos 
Sectional  view. 


BEARD  S    METHOD  245 

means  of  small,  mouse-tooth  forceps,  the  edge  of  the  lower  flap  is 
seized  between  the  corresponding  threads,  pulled  up  and  rolled 
backward,  and  placed  in  apposition  with  the  tarso-orbital  fascia 
just  where  the  thread  enters  the  fold  therein.  The  two  ends  of 
thread  are,  meanwhile,  drawn  ii])  pretty  well,  biil  not  tightly,  and 
tied  in  a  single  surgical  knot  over  a  short  cylinder  of  firmly  rolled 
gauze  or  absorbent  cotton.  The  same  is  done  relative  to  the  (lap 
and  other  suture.  Before  fmishing  the  knots,  it  is  seen  to  that  the 
edges  of  both  skin  flaps  are  directed  backward;  in  other  words,  not 
coapted  one  with  the  other,  but  that  both  are  in  contact  with  the 
broad  ligament  of  the  tarsus.  In  this  way  the  resulting  cicatrix 
is  completely  hidden  by  a  normally  i)laced  and  normally  appearing 
sulcus. 

Lastly,  the  sutures  are  tightened  as  much  as  is  needed  for  the 
desired  effect,  and  are  tied  in  bowknots.  In  the  extreme  cases  it 
will  be  impossible  for  the  patient  to  close  the  lids  so  long  as  the 
sutures  are  in.  As  this  is  for  only  two  or  three  days,  during  which 
time  a  carefully  applied  dressing  and  bandage  is  worn,  there  is  no 
danger  to  the  cornea.  Nothing  more  is  expected  of  the  sutures  than 
to  hold  the  operated  parts  in  their  new  relations  until  primary  union 
is  assured;  that  is  to  say,  they  are  not  left  in  position  to  suppurate 
or  to  cut  through.  The  tension  of  the  threads  may  be  altered  at  any 
time  within  twenty-four  to  thirty-six  hours,  if  one  wishes  to  qualify 
the  primary  results,  by  merely  undoing  the  bowknot  and  loosening 
or  tightening  the  other  one,  as  the  conditions  demand.  In  removing 
the  sutures,  the  rolls  over  which  they  are  tied  are  pulled  smartly  up, 
both  threads  are  cut  off  close  to  the  skin  and  withdrawn  by  seizing  the 
loop  below.     In  this  way  no  soiled  portion  passes  through  the  tracks. 

I  consider  the  Hotz  idea,  as  embodied  in  this  procedure,  to  con- 
stitute, probably,  one  of  its  most  salient  advantages,  and,  taken  all 
in  all,  theoretically  as  well  as  practically,  it  seems  to  possess  some  of 
the  best  points  of  other  ptosis  operations,  and  eliminates  some  of 
their  worst  faults.  It  is  adapted  to  all  the  ordinary  forms  of  ptosis, 
the  degree  of  effect  being  governed  by  the  height  of  the  fold  made 
in  the  broad  ligament  of  the  tarsus,  its  distance  from  the  ui)per 
border  of  the  tarsus,  and,  in  some  measure,  by  the  distance  of  the 
primary  incision  from  the  free  border  of  the  lid. 

Narcosis  is  employed  only  when  necessary.  Cocain  solution 
injected  into  the  skin  is  less  of  a  liel])  than  a  hindrance.  It  is 
usually  drop])ed  into  the  o])en  wound,  but  it  is  of  doubtful  benelit. 


246  OPERATIONS    FOR    PTOSIS 

Summary. — In  the  foregoing  chapter  an  attempt  has  been  made 
to  give,  by  describing  example  ptosis  operations,  an  idea  of  some  of 
the  many  different  methods,  and  to  illustrate  the  guiding  principle 
in  each  instance.  In  the  primitive  operation  of  excising  a  segment 
of  skin  mere  shortening  of  the  lid  was  the  aim  and  the  end. 
Naturally,  this  can  only  be  applicable  to  cases  characterized  by  an 
actual  redundance  of  integument,  i.e.,  cutaneous  ptosis,  or  blepharo- 
chalasis,  for,  in  general,  the  lids  of  ptosic  subjects  are  already  too 
scant.  This  is  particularly  true  of  congenital  ptosis,  in  which  the 
lids  are  short,  flat,  and  devoid  of  any  sulcus  in  the  skin.  In  the 
operation  of  von  Graefe  the  object  was  the  weakening  of  the  an- 
tagonist of  the  levator  or  the  orbicularis,  and  was  manifestly 
faulty  in  the  premises.  The  Bowman-Gillet  de  Grandemont 
methods  are  similar  to  von  Graefe's  in  that  they  really  amount  to 
subcutaneous  shortening  of  the  lid;  but  they  are  an  improvement 
in  so  far  as  they  effect  an  advancement  of  the  elevators  of  the  tarsus. 
As  to  the  palpebro-frontal  ligament  of  Dransart,  as  represented  in 
the  original  operation  and  in  those  of  Mules,  Bishop,  Wilder,  and 
others,  there  is  no  denying  that  the  results  are  positive,  but  they  are 
mainly  due  to  shortening.  There  is  no  definite  advancement  of  the 
normal  elevators,  the  lifting  of  the  lid  is  relegated  almost  wholly 
lo  the  frontalis,  which  is  but  a  poor  substitute,  and  besides,  a 
foreign  body  is  left  in  the  tissues;  not  the  least  objection  to  this  is 
that  it  is  sometimes  extruded.  They  would  seem  to  be  superior  to 
those  other  methods  that  are  employed  for  putting  the  lid  in  more 
direct  connection  with  the  frontalis,  whereby  tongues  or  strips  of 
muscle  are  transplanted.  The  frontalis  owes  its  power  of  lifting  the 
eyebrow  to  the  fact  that  its  attachment  is  essentially  to  the  skin; 
hence,  procedures  that  call  for  deep  or  extensive  incisions  and 
other  traumatism  in  the  superciliary  region  must  result  in  scars  that 
inevitably  limit  the  natural  movement  of  the  parts.  Then,  too, 
these  engrafted  fragments  will  atrophy,  and  the  eft'ect  obtained  will 
diminish  with  the  lapse  of  time.  The  palpebro-frontal  ligaments 
are  peculiarly  suited  to  cases  in  which  both  the  levator  and  the 
superior  rectus  arc  ])owcrless.  In  the  mode  of  Pagenstechcr,  of 
gradually  tightening  ligatures,  the  object  was  the  coupling  of  the 
lid  to  the  frontalis  by  means  of  cicatricial  cords,  and  looked  to  a 
determinate  result  through  a  most  precarious  and  irregular  medium, 
viz.,  the  exciting  of  an  inllammatory  or  suppurative  process.  In 
the  procedure  of  iMcrsbuscIi  and  liis  followers  the  object  souglit  is 


SUMMARY  247 

the  shortenin,!^  or  advancement  of  the  levator,  and  its  futility  as  a 
systematic,  all-arouud  process  would  apjiear  lo  lie  in  the  fact  that  the 
muscle  concerned  is,  in  the  great  majority  of  cases,  either  absolutely 
inert  or  of  extremely  insignificant  force.  While,  therefore,  the 
sphere  of  these  measures  is  thus  limited,  they  are  theoretically  suit- 
able only  for  a  certain  small  number  of  cases  in  which  the  levator  is 
fairly  potent,  as  in  trachomatous  ptosis.  But,  as  a  matter  of  fact, 
they  have  a  much  wider  range  of  usefulness,  of  which  more  anon. 
The  Motais-Parinaud  measures  are  happily  imagined  and  rest 
upon  a  physiologic  as  well  as  a  scientific  basis.  Yet  they  depend 
for  their  success  upon  the  integrity  of  the  superior  rectus;  and  in  a 
large  percentage  of  cases  of  ptosis  there  is  paralysis  or  marked 
insufiiciency  of  the  muscle.  Theoretically  considered,  the  very  pro- 
nounced drawing  forward  of  the  superior  rectus  that  would  be  req- 
uisite for  the  correction  of  an  extreme  ptosis  by  these  methods 
would  result  in  undue  tension  diplopia  and,  possibly,  vertical 
squint.  They  would  find  their  best  application,  then,  to  the  lower 
grades  of  ptosis  in  which  the  superior  rectus  is  of  normal  strength. 
According  to  Terson,^  of  the  considerable  number  of  operations 
of  this  kind  that  have  been  recently  performed,  some  have  been 
follow^ed  by  good  results,  and  others  not  only  by  failure,  but  by 
corneal  complications — the  latter  even  leading  to  anterior  staphy- 
loma. Moreover,  the  eye  is  said  to  be  more  prone  to  remain  open 
during  sleep  after  the  Motais-Parinaud  methods  than  after  other 
operations  for  ptosis. 

Shoemaker,  of  Philadelphia,  in  the  Annals  of  Ophthalmology, 
Oct.,  1907,  makes  certain  pertinent  remarks  as  to  the  Motais  opera- 
tion from  the  theoretic  standpoint.  For  instance,  he  says,  "  Motais 
claims  to  supply  a  perfect  physiological  substitute  for  the  levator 
by  such  a  transplantation  of  the  superior  rectus  tendon.  This  is  not 
actually  the  case,  but  the  lid  after  the  Motais  operation  is  held  in  its 
new  position  by  anchorage  to  a  fixed  point  on  the  eyeball,  so  that 
there  can  be  no  elevation  or  movement  of  the  lid  through  the  trans- 
planted portion  of  the  superior  rectus  independent  of  the  eyeball." 
Did  the  writer  of  these  w'ords  bear  in  mind  how  slightly,  even  in 
the  normal  eye,  the  levator  can  act  independently  of  the  elevators  of 
the  globe?  Shoemaker  further  says  that  the  tongue  or  slip  of  the 
superior  rectus  is  perfectly  inextensiblc  if  made  of  tendon,  as  was 
the  intention,  and   that   if   made   ten   millimeters  long,  as  ^Motais 

1  Encyclopedie  Fran^aise  d'ophtalmologie,  vol.  v,  p.  408,  1906. 


248  OPERATIONS    FOR    PTOSIS 

specified,  it  would  reach  into  the  muscle  and  be  apt  to  part  upon 
the  slightest  tension.  Yet  he  thinks  the  possible  effect  to  be 
derived  from  the  operation  is  great,  and  when  little  or  no  effect  is 
obtained  he  believes  the  cause  of  the  failure  lies  in  transplanting 
the  slip  among  the  libers  of  the  orbicularis,  instead  of  securing  it 
to  the  tarsus,  and  that  this  is  particularly  apt  to  occur  when  the 
stitch  is  tied  on  the  skin,  as  the  tendon  is  then  drawn  away  from 
the  tarsus.  To  be  sure  that  the  slip  is  attached  to  the  tarsus  he 
would  suggest  the  open  method,  as  follows: 

The  first  stage  of  the  operation  remains  unchanged  except  that 
in  passing  the  double-armed  thread  through  the  prepared  tendon 
slip,  pass  the  needles  from  above  downward,  placing  the  loop  on 
the  upper  surface.  Then  make  a  horizontal  incision  through  the 
skin  of  the  lid  and  the  orbicularis  muscle  down  to  the  tarsus  a  little 
below  its  upper  margin.  Undermine  the  orbicularis  fibres  by 
pushing  them  upward  or  backward,  exposing  the  tarsus  to  its  upper 
margin.  Buttonhole  Miiller's  muscle  and  the  conjunctiva  and 
through  this  opening  carry  the  sutures  with  the  piece  of  tendon,  and 
fasten  the  latter  directly  to  the  surface  or  edge  of  the  tarsus  precisely 
as  we  do  the  tendon  to  the  sclera  in  an  ordinary  advancement. 
Having  dipped  each  needle  into  the  tarsus  and  brought  tarsus  and 
tendon  slip  into  direct  contact,  restore  the  orbicularis  fibres,  carry 
the  needles  through  them  and  the  skin,  and  tie.  Close  the  wound 
in  the  lid  with  two  or  more  stitches. 

He  thinks  permanent  paralysis  of  the  superior  rectus  is  not 
necessarily  a  contraindication  to  Motais  operation,  but  may  be 
rather  an  advantage,  and  he  sees  no  reason  why,  in  such  a  case, 
the  whole  tendon  should  not  be  transplanted  and  put  to  some  use. 
A  positive  contraindication  would  be  a  thin,  poorly  developed 
superior  rectus. 

The  laying  bare  of  the  tarsus,  as  proposed  by  Shoemaker,  doubt- 
less has  its  advantages.  Not  the  least  of  these  being  the  greater 
facility  it  affords  for  the  definite  and  precise  disposition  of  the 
transplanted  tongue.  My  colleague  Wilder  has  been  the  first,  I 
believe,  to  put  Shoemaker's  idea  into  execution.  This  he  has  done 
of  late  in  several  instances,  and  expresses  himself  as  well  pleased 
with  the  outcome.  In  addition  to  adopting  Shoemaker's  proposal, 
Wilder  has  added  a  feature  of  his  own.  He  reasoned,  and  rightly, 
that  the  Httlc  tongue  gives  hardly  more  than  a  single  point  of  su])- 
port  to  the  lid,  and  vwn  thought  that  he  ()l)ser\ed,  in  a  case  that  had 


COMMENTS    ON    THE    MOTAIS    MKASURE  249 

been  operated  upon  by  the  Motais  method,  that  the  free  border  of 
the  uj)per  lid  showed  a  sort  of  notch  corresponding  to  the  point  of 
attachment  of  the  tongue.  To  avoid  this,  as  well  as  to  serve  as 
auxiliaries  to  the  delicate  tongue  in  holding  up  the  lid,  he  places  a 
slowly  absorbable  suture  in  the  ligament  of  the  tarsus  on  either  side 
of  the  buttonhole  through  which  the  tongue  is  drawn,  and  in  such 
a  manner  as  to  slightly  fold  said  ligam.ent.  He  thus  combines  with 
the  Motais  measure  something  of  that  of  Eversbusch — or  a  slight 
shortening  or  tucking  of  the  levator  tendon. 

Objections  to,  or  criticisms  of,  a  measure  on  purely  theoretical 
grounds,  no  matter  how  cleverly  conceived  nor  how  logically 
argued,  are  not  necessarily  valid  nor  conclusive.  Many  reports 
have  been  made  in  ophthalmic  hterature  of  most  excellent  results 
obtained  with  the  Motais  operation.  Notable  among  those  made 
in  this  country  is  that  of  H.  D.  Bruns,  of  New  Orleans. 

The  present  ^^Titer  has  performed  it  in  sixteen  cases.  Two  of 
these  were  trachomatous  ptosis  of  high  degree.  In  one  the  lid  had 
fallen  completely.  Since  the  upper  borders  of  the  tarsi  had  under- 
gone trachomatous  degeneration,  they  were  excised  at  the  same  time, 
thus  allowing  the  anchorage  of  the  tongue  to  be  made  at  the  middle 
of  the  tarsus  instead  of  at  the  upper  border.  The  outcome  of  these 
cases  was  so  singularly  gratifying  that  I  wondered  if  it  were  not 
best  oftener  to  combine  the  operation  with  a  slight  excision  of  the 
tarsus.  I  have  recently  seen  a  recommendation  to  that  effect  by  a 
French  author.  In  the  operations  just  referred  to  it  was  necessary 
first  to  make  a  free  canthotomy,  in  order  the  better  to  manage  the 
upper  lid,  there  having  been  considerable  atrophy  of  the  conjunctiva. 

In  addition  to  the  two  cases  just  mentioned,  my  sixteen  included 
ten  of  congenital  ptosis  and  one  from  traumatic  paralysis  of  the 
levator.  The  results  in  all  of  them  are  far  and  away  the  best  I  have 
ever  obtained  in  this  affection.  As  concerns  the  last  case  operated 
it  was  feared  for  a  time  that  either  the  tongue  had  broken,  or  the 
suture  had  pulled  out  of  it,  but  this  fear  proved  to  be  groundless. 
The  manner  in  which  the  free  border  of  the  upper  lid  keeps  out  of 
the  way  of  the  pu])il,  as  the  subject  looks  further  and  further  up- 
ward, is  truly  beautiful  to  contemplate.  As  regards  annoying 
diplopia,  upward  squint,  inability  to  keep  the  lids  closed  during 
sleep,  etc.,  I  have  not  observed  any  of  these.  It  is  true,  however, 
that  one  can,  soon  after  the  operation,  demonstrate  hyi)ertroi)ia. 
According  to  this  ])hase  of  the  subject,  one  would  naturally  conclude 


250  OPERATIONS    FOR    PTOSIS 

that  cases  of  bilateral  ptosis,  ha\'ing  both  eyes  operated,  would  be 
more  likely  to  escape  this  complication  than  would  the  monolateral 
ones. 

I  find  that  in  congenital  ptosis  the  lack  of  power  in  the  superior 
rectus  is  main'y  due  to  non-use,  for  these  subjects  have  no  oc- 
casion to  rotate  the  globe  upward.  By  careful  examination  it  can 
usually  be  demonstrated  that  there  is  limited  function  in  the  muscle. 
No  matter  how  little  there  is,  the  Motais  operation  is  the  one,  in  my 
opinion,  that  should  be  chosen.  After  the  lid  is  once  raised  the 
superior  rectus  develops  more  and  more  its  proper  function.  Herein 
lies  the  explanation  of  a  unique  and  most  gratifying  feature  of  the 
Motais  method,  viz.,  the  constantly  increasing  enchancement  of 
the  effect  for  weeks  and  even  months  after  the  operation. 

The  axes  of  vision  in  normal  eyes  are  never  divergent — never 
even  parallel.  They  must  meet  at  the  object  fixed.  Hence,  they  are 
always  more  or  less  convergent.  In  the  visual  act  by  which  one 
earns  his  livelihood  they  are,  in  most  instances,  strongly  convergent. 
Moreover,  it  is  to  be  remembered  that  the  superior  rectus  (together 
with  the  inferior  rectus)  is  an  adductor  muscle.  It  is  important 
then  in  transplanting  the  central  portion  of  the  tendon  of  the  superior 
rectus  into  the  upper  lid— or  onto  the  upper  tarsus — to  place  it  some- 
what to  the  nasal  side  of  the  center  of  the  tarsus,  in  order  to  give  it 
the  most  direct  action  in  lifting  the  lid.  To  place  it  in  the  center, 
or  to  the  temporal  side  of  the  center,  would  cause  it  to  overlap  the 
outer  third  of  the  tendon  in  the  habitual  position  of  the  globe. 

A  little  study  is  invited  of  the  accompanying  drawing  (Fig.  132), 
which  is  a  tolerably  accurate  representation,  in  vertical,  median  sec- 
tion, of  the  tissues  concerned  in  the  surgery  of  ptosis.  This  will  dem- 
onstrate that  any  measure  which  folds  or  in  any  way  shortens  the 
broad  ligament  of  the  tarsus,  not  only  advances  the  levator  and 
Miiller's  muscle,  but  also  tightens  up,  or  advances,  the  levator  por- 
tion of  the  tendon  of  the  superior  rectus.  It  follows  that,  as  single, 
constant  measures,  the  class  of  operations  treated  of  under  the  second 
category,  viz.,  the  advancement  of  the  natural  elevators,  are,  perhaps, 
those  deserving  of  the  greatest  confidence.  Granting  that  those  in 
tlie  first  class — the  linking  of  the  lid  to  the  frontalis — are  as  effective 
in  lifting  up  and  holding  the  lid,  the  feat  is  accomplished  in  an 
unnatural  manner;  that  is,  the  lid  is  ])ulled  straight  up,  not  rolled 
back  and  up,  normally,  like  the  visor  of  a  helmel;  moreover,  the 


CHOICE    OF    MKTIIOI)  2ST 

forehead   is  corrugated   in  the  act,  thus  adding  another  deformity. 
We  have  noted  the  limitations  of  those  in  the  third  class. 

All  who  have  had  much  experience  in  this  branch  of  ophthalmic 
surgery  will  agree  that  the  results  of  j)tosis  operations,  taken  all  in 
all,  are  far  from  brilliant.  "It  is  only  with  precise  appreciation  of 
the  peculiarities  of  the  individual  case,  that  one  may  hope  to  succeed 


Fig.  132. — Lev.,  Levator  muscle.  S.R.,  Superior  rectus  muscle.  S,  Sclera. 
U.F.,  Upper  fornix.  M,  Muscle  of  Muller.  I,  Iris.  C,  Cornea.  L,  Lens. 
I,  Scleral  portion  of  superior  rectus  tendon.  2,  Levator  portion.  3,  Conjunctival 
portion.  L.T.,  Levator  tendon.  S.O.,  Septum  orbitale.  F,  Frontal  muscle.  S-C, 
Super-cilia.  E,  Expansions  of  the  levator  tendon.  T,  Tarsus.  The  lids  are 
represented  closed. 


in  this  delicate,  and  special  surgery  of  the  lid"  (Terson).  A  correct 
diagnosis  as  to  the  character  of  the  ptosis  and  a  nice  estimate  as  to 
its  degree,  are  pre-requirements  to  a  fortunate  issue.  The  high 
degrees  of  congenital  ptosis,  with  inert  superior  rectus,  are  the 
most  difficult  with  which  to  contend.  It  is  in  these  that,  according 
to  the  writer's  observation,  the  greatest  good  is  to  be  looked  for 
from  those  surgical  measures  that  do  not  rely  for  their  success  uj^on 
a  single  feature  or  principle,  but  uj)on  a  n'eU-cousidcrcd  union  of  two 


252  OPERATIONS    FOR    PTOSIS 

or  more.  In  this  manner  one  is  not  obliged  so  to  exaggerate  a 
particular  step  as  to  risk,  for  example,  the  production  of  unsightly 
and  harmful  lagophthalmos,  but  is  enabled  to  obtain  a  maximum 
effect  with  a  minimum  disturbance  of  any  one  of  the  several  parts 
involved.  For  the  milder  forms  of  partial  ptosis  all  the  measures 
that  have  just  been  described  readily  give  satisfactory  results  in 
good  hands  and  in  well-selected  cases.  After  all,  it  is  here,  just 
as  with  surgery  in  general,  that  subtle  something  known  as  personal 
equation  is  a  tremendous  factor.  A  chosen  few  seem  to  be  lucky, 
whatever  the  methods  thev  select. 


CIIAPI'KR  VJI. 
KNTROPION. 

Entropion,  or  turning  inward  of  ihc  lid  upon  the  globe,  is  of 
two  kinds  functional  and  organic.  The  evil  results  of  the  condi- 
tion have  reference,  mainly,  to  the  damaging  effects  upon  the  cornea 
and  conjunctiva  caused  by  the  contact  of  the  misplaced  eyelashes, 
or  trichiasis;  though  the  deformity,  and  the  pressure,  and  the 
rubbing  of  the  warped  and  shrunken  tarsi  upon  the  globe,  in  the 
worse  forms  of  organic  entropion,  are  alone  suflicicnt  reasons  for 
surgical  intervention. 

Functional  or  spastic  entropion  usually  concerns  the  lower 
lid  only,  and  occurs  most  often  in  elderly  persons  in  whom  the 
palpebral  integument  is  lax  or  superabundant.  It  is  then  known 
as  senile  entropion,  and  a  common  cause  is  the  wearing  of  a  bandage. 
Not  infrequently,  however,  it  affects  the  lower  lid  of  younger  sub- 
jects, when  it  is  accompanied  by  inflammations  of  the  skin  and  of 
the  conjunctiva.  This  form  of  spasmodic  turning  in  has  been 
called  acute  entropion.  Whate\er  the  cause  or  the  age  of  the  indi- 
vidual, they  are  treated  about  alike;  that  is,  for  the  transient  or  less 
obstinate  varieties  simple  mechanical  means  are  successfully 
employed,  and  for  the  more  stubborn,  surgical  measures  are 
required. 

If  from  bandaging,  and  it  is  not  practicable  to  leave  off  the  dress- 
ing, a  strip  of  rubber  adhesive  plaster  five  or  six  centimeters  long, 
by  one  to  one  and  one-half  wide  is  applied  vertically.  About  one 
centimeter  of  the  upper  end  is  first  made  to  adhere  just  below  the 
cilia,  pulled  downward  slightly,  to  draw  the  free  border  away 
from  the  eye— not  so  much  as  to  produce  a  decided  ectropion— then 
fastened  throughout  the  rest  of  its  extent.  If  there  is  any  lacrima- 
tion,  the  tears  soon  loosen  the  plaster,  in  which  event  it  is  better  to 
gently  evert  the  lid  and  to  paint  llexible  collodion  over  the  region 
of  the  lower  half  of  the  orbicularis,  taking  care  to  close  the  eye  and 
otherwise  protect  it  from  the  ether. 

A  more  efticient  way  is  to  cut  a  small  slri])  of  gauze  or  other 
suitable  fabric,  lay   it  on  tlie  part,  and  glue  it  down   by  smearing 

2s ; 


!54 


ENTROPION 


on  the  collodion  (Fig.  133).  As  with  the  ])Iaster,  the  upper  end  is 
made  fast  first,  allowed  to  dry,  tlicn  drawn  down,  and  the  whole 
made  to  stick.  If  the  entropion  persists  in  spite  of  the  continuance 
of  such  treatment  for  a  reasonable  time  after  the  exciting  cause  has 
been  removed,  some  form  of  operation  is  resorted  to  as  a  choice  of 
two  evils;  for,  while  lid  abscess  and  c\-en  phlegmon  of  the  orbit  are 


Ap 


ll()<li(>ni/.i-(l  irauze  for  sp. 


•titnijiion  of  lower 


known  to  ha\e  resulted  from  the  sort  of  surgery  in  question,  the 
trilling  risk  therefrom,  as  compared  with  the  sure  harm  to  the  cornea 
and  conjunctiva  that  will  follow  the  ])rolonged  friction  of  the  lashes, 
is  not  to  be  considered.  If  the  entropion  be  still  purely  spastic, 
onC  of  the  safest  and  most  effective  remedies  is  canthoplasty,  with 
free  division  of  the  external  canthal  ligament — the  cantliolysis  of 
Agnew — as  described  in  its  ])roper  place. 


SUTURE    OPKRATIOXS  255 

One  may  also  ha\c  recourse  lo  one  of  the  suture  operations. 
These,  of  which  a  numl)cr  have  been  devised,  consist  in  inserting  a 
thread  or  a  series  of  threads,  vertically  in  the  tissue  of  the  lower 
lid,  that  through  the  tying  or  through  the  consequent  cicatrizing 
will  correct  the  entro])ion.  The  forerunner  of  most  of  ihem  was 
that  of  Hippocrates,  who  passed  a  ligature  through  a  horizontal 
fold  of  the  skin  just  beneath  the  free  border,  and  allowed  it  to 
suppurate  out.  Gaillard^  entered  from  one  to  three  curved  needles, 
carrying  silk  thread  into  the  skin  just  beneath  the  lashes,  that 
penetrated  to  the  tarsus,  followed  its  anterior  surface,  thus  including 
skin  and  orbicularis,  and  emerged,  straight  below,  some  fifteen 
millimeters  or  more  from  the  point  of  entrance,  according  to  the 
degree  of  redressal  required.  They  were  tied  tightly  and  left  till 
their  spontaneous  release. 

Arlt-  modified  Gaillard's  method  (Fig.  134)  so  that,  in  accordance 
with  present  ideas,  it  might  be  thus  described : 

Two  No.  3  braided  black  silk  sutures,  previously  boiled  in 
vaselin-paraffin  and  otherwise  aseptically  prepared,  are  needed, 
each  of  which  is  armed  with  two  curved  needles.  With  left  finger 
and  thumb  a  horizontal  fold  of  the  skin  large  enough  to  correct 
the  defect  is  picked  up  beneath  the  affected  lid.  One  pair  of  the 
needles  is  made  to  penetrate  the  base  of  the  fold  on  the  same  level, 
two  or  three  millimeters  apart,  and  about  the  same  distance  (three 
millimeters)  from  the  free  border — one  on  either  side  of  the  junction 
of  the  middle  with  the  outer  third  of  the  lower  lid.  They  are  passed 
downward  between  tarsus  and  muscle,  and  brought  out  as  in  the 
Gaillard  operation.  The  other  pair  is  similarly  introduced,  astride 
the  junction  of  the  middle  and  inner  thirds  of  the  lid.  In  tying,  a 
cylinder  of  some  soft  material  is  placed  beneath  both  knots  and  under 
both  loops,  wdiilst  a  large  probe  or  other  round  instrument  is  pressed 
against  the  tarsus  to  make  it  cave  inward.  A  bandage  is  applied 
until  the  sutures  are  removed  at  the  end  of  forty-eight  hours. 

Snellen's^  Sutures.— The  eye  is  cocainized.  The  edge  of  the 
lid  is  seized  with  a  pair  of  T  forceps,  or  with  the  lingers,  and  everted 
enough  to  open  the  cul-de-sac,  in  the  bottom  of  which  the  needles 
are  started  (Fig.  135).  One  needle  of  a  double-armed  suture  is 
here  passed  (convexity  downward)  directly  through  the  whole  thick- 

1  Bull,  de  la  Soc.  med.  de  Poetiers,  1844. 
-  Die  Krankh.  des  Aug.,  iii,  S.  368,  1S5O. 
3  Cong,  internat.  d'oph.,  Paris,  1863. 


256 


ENTROPION 


ness  of  ihc  lid,  just  external  to  the  lacrimal  punctum,  and  the  other 
through  about  four  millimeters  further  outward,  while  the  resultant 
loop  is  drawn  down  into  the  fornix.  The  point  of  each  needle  is 
then  inserted  at  its  place  of  exit  from  the  skin,  passed  upward  be- 
neath the  latter — not  beneath  the  muscle — one  parallel  with  the  other 
(their  convexities  backward),  and  brought  out  two  millimeters  below 
the  cilia.     One  or  two  other  threads  are  placed  in  precisely  the 


Fig.  134. — Arlt's    uturc  for  entropion.  Fig.  135. — Snellen's  suture  for  entropion. 


same  manner.  The  lid  is  turned  outward,  over  a  round  instrument 
of  some  kind,  and  the  sutures  are  tied  over  cylinders  and  left  in 
three  or  four  days,  the  eye  being  bandaged  meanwhile. 

Stellwag's  sutures  (Fig.  136),  like  Snellen's,  began  by  loops  at 
the  bottom  of  the  lower  fornix,  but  instead  of  passing  iirst  through 
the  lid,  were  directed  up  and  forward  between  the  tarsus  and  the 
orbicularis,  to  emerge  from  the  skin  near  the  cilia. 

Graefe,'  in  some  cases  of  spastic  entro])ion,  picked  up  a  small 

'  ll.idcll.erg  Cong.,  1868. 


SIMPI.K    KXCISIOX    01'    SKIX 


57 


vertical  fold  of  skin,  two  or  three  millimeters  wide,  near  the  center 
of  the  free  border,  passed  a  thread  through  its  ui)i)er  end,  lied  it, 
and  cut  one  end  off  short.  This  was  repeated  directly  below, 
over  the  rim  of  the  orbit,  and  the  two  long  ends  of  thread  were 
knotted  over  cotton  or  gau/e.  One  or  more  were  em])l()yed  as  the 
case  demanded. 

The  excision  of  a  strip  of  the  extreme  border  fibres  of  the  lower 
section  of  the  orbicuhiris,  through  an  incision  close  to  the  cilia,  is 


Fig.  136. — Stelhvag's  suture  for  ectropion. 

effective  and  proper  for  tlie  relief  of  recent  spastic  entropion  and  is 
sometimes  successful  after  the  simple  sutures  have  failed. 

The  simple  excision  of  a  section  of  skin  in  the  form  of 
ellipses,  triangles,  etc.,  of  greater  or  lesser  extent,  after  the 
fashion  of  the  ancients,  is  still  practised,  to  a  limited  extent,  for 
functional  entropion  as  well  as  for  the  cicatricial  variety.  The 
opening  is  cither  closed  by  suturing  or  is  left  raw  to  heal  by  granula- 
tion (Desmarres). 


258  ENTROPION 

Another  primitive  cure  is  linear  cauterization  of  the  skin  along 
the  border.  Both  these  measures  are  irrational  and  fogyish. 
The  mere  fact  that  they  do  away  with  the  entropion  in  most  in- 
stances does  not  render  them  free  from  censure,  and  they  may  be 
easily  pushed  to  such  an  extreme  as  to  cause  the  substitution  of  one 
blemish  for  another,  such  as  lagophthalmos,  unseemly  scars  and 
ectropion.  It  is  doubtful  if  sheer  redundance  of  skin  is  ever  the 
true  cause  of  entropion,  but  it  is  certain  that  the  removal  of  it  will 
pull  the  lid  away  from  the  eye— so  might  many  an  odd  contrivance. 

ORGANIC  OR  CICATRICIAL  ENTROPION. 

UPPER    LID. 

This  form,  unlike  the  functional,  consists  not  so  much  in  the 
malposition  as  in  the  malformation  of  the  lid,  the  chief  factors  in 
which  are  the  warping  of  the  tarsus,  through  the  transformation  of 
this  body  into  cicatricial  tissue,  and  the  atrophy  and  consequent 
shrinkage  of  the  conjunctival  sac. 

The  causes  are  diseases  such  as  chronic  inflammations  and  ul- 
cerations, beginning  in  the  conjunctiva,  the  results  of  infection, 
burns,  and  other  injuries.  The  greatest  of  all  agents,  both  as  to  its 
capability  and  its  frequency,  in  the  production  of  cicatricial  entropion 
is  chronic  granular  conjunctivitis,  or  trachoma.  The  countries 
bordering  on  the  Mediterranean  Sea  have  from  the  times  of  their 
earliest  history  been  peculiarly  subject  to  this  affliction,  hence, 
they  early  began  to  devise  surgical  means  for  the  relief  of  trichiasis, 
which  is  the  greatest  evil  of  entropion. 

This  form  differs  in  another  respect  from  functional  entropion, 
viz.,  that  it  more  generally  concerns  the  upper  lid.  In  dealing  with 
entropion  from  trachoma,  therefore,  it  is  well  to  keep  in  view  the 
manner  of  its  production;  in  other  words,  the  clinical  characteristics 
of  the  disease  which  produces  it,  as  constituting  the  rationale 
for  its  best  and  most  progressive  surgery.  The  features  that  have 
a  special  bearing  may  be  stated  thus: 

1.  Principal  Seat. — The  upper  conjunctival  fornix. 

2.  The  intense  photophobia,  which  is  the  earliest  factor  in  the 
causation  of  entropion.  Through  it  an  abnormal  development  of 
the  orbicularis  ensues,  especially  of  the  palpebral  or  inner  zone  of 
the  muscle  which  remans  after  the  acute  stages  of  the  disease  have 


CICATRICIAL 


259 


passed.  By  its  action  the  tension  of  the  lids  u[)on  the  ^lobc  becomes 
excessive,  the  friction  is  increased,  and  the  protecting,  sharp,  inner 
angle,  containing  the  musculus  ciliaris  of  Riolani,  disappears,  the 
free  border  becomes  ivhcttcd  down,  by  absorption,  to  a  feather  edge, 
and  the  iinderhanging  skin  contains  the  lashes. 

3.  The  atrophy  of  the  entire  conjunctival  sac  and  the  whole  of 
the  tarsi  that  are  responsible  for  the  shrinkage  and  distortion  of 
these  parts — a  process  that,  once  well  under  way,  seems  never  to 
come  to  an  end  until  death. 

Nos.  2  and  3  are,  probably,  both  concerned  in  the  bringing 
about  of  the  varying  degrees  of  ptosis  that  are  so  often  associated 
with  entropion.  The  levator  gradually  yields  to  the  prolonged 
antagonism  of  the  powerful 
orbicularis  and  to  the  oblit- 
eration of  the  upper  fornix, 
through  atrophy  of  the  con- 
junctiva, and  becomes  per- 
manently disabled. 

Incipient,  or  slight  cic- 
atricial entropion,  when 
the  cause  of  it  is  no  longer 
active,  can  rarely  be  corrected 
by  one  of  the  operations 
described  for  the  functional 
kind.  Here  tissue  has  been 
destroyed  that  must  usually  be  replaced. 

The  first  important  operation  of  which  there  is  a  definite  account 
is  that  described  in  the  medical  works  of  .^tius,  written  in  the 
sixth,  and  those  of  Paulus  ^Egineta,  in  the  seventh  century  of 
the  present  era.  Briefly,  it  was  as  follows:  The  free  border  was 
divided  vertically,  from  canthus  to  canthus,  into  two  leaves — the 
anterior,  composed  of  the  skin  holding  the  cilia  and  their  follicles; 
the  posterior,  of  the  tarsus  and  conjunctiva.  An  ellipse  of 
integument,  the  length  of  the  palpebral  fissure,  was  removed  just 
above  the  roots  of  the  lashes,  and  the  latter,  with  their  loosened 
bridge,  slid  up  and  fixed  to  be  out  of  the  way.  This  is  the  iden- 
tical operation  that  was  revived  by  G.  Jasche  ^  and  that,  modified 
by  V.  Arlt,2  had  such  a  tremendous  though  ephemeral  vogue,  under 

1  Med.  Ztg.  Russlands,  No.  q,  1844. 

2  Graefe-Saemisch,  Bd.  iii,  1874. 


Jasche- Arlt,  No.  i. 


2  6o 


ENTROPION 


the  name  of    "  Verabschiebung   des  Wim])crbodens  nach  Jiische- 
Arlt,"  or,  in  English,  transplantation  of  the  eyelashes  (Figs.  137  and 

13S). 
The  great  faidts  of  this  procedure  were:  (a)  want  of  a  fixed  point 

above  for  the  upper  edge  of  the  flap;   {h)   lack  of  support  from 

below,  so  that  the  cilia  gradu- 
ally descended  until  they 
again  rested  on  the  eyeball; 
and  (c)  no  attention  was  paid 
to  the  incurvation  of  the 
tarsus;  nor  {d)  to  the  atrophy 
of  the  conjunctiva  and  restora- 
tion of  the  free  border;  (c)  to 
the  relief  of  lid  tension;  (/) 
to  drawing  up  the  loose  under- 
hang  of  the  cilia;  nor  {g)  the 
counteracting  of  the  tendency 


-Jaschc-Arlt,  No.  2. 


to  ptosis. 

The  need  (a)  was  found  by  Anagnostakis,^  of  Athens,  wdio  chose 
the  upper  border  of  the  tarsus  (Fig.  139).     He  made  a  cutaneous 
incision  the  length   of  the  tarsus,  only  three  millimeters  from   the 
free   border,    opened     it    up, 
and    resected    a   strip  of  the 
orbicularis  overlying  the  upper 
border  of  the  tarsus,  and  to 
the  latter  stitched    the    lower 
lip  of  the  skin  incision.     The 
upper  lip  was  not  included  in 
the    sutures.      This    method 
failed  in  all  the  other  require- 
ments save  (a). 

Hotz,2  of  Chicago,  modified 
this  proceeding  by  making  the 
[)rimary  incision  higher  up 
and  ])aralk-l  with  the  upper 
tarsal  border,  to  give  a  normal 

sulcus  with  the  scar  at  its  bottom  (Fig.  140).     He  passed  the  sulure^ 
through  the   upi)cr  lij)  of  the  skin  incision  also  before  tying,  and 


,\nap;nostak 


1  Annul,  d'oculist.  1.  xxxviii,  p 

2  Archives  of  (3i)lilhalmology,  ^ 


:S57. 
•iii,  ]) 


GAYET  S    METHOD 


j6i 


most  important  of  all,  insisted  ui)on  the  resection  of  the  lower  fibres 
of  the  orbicularis — thus  partly  fulfillinj^  indication  (>•).  To  Hotz  is 
really  due  the  credit  of  perpetuating  the  princij>le  adduced'  by 
Anagnostakis,  and  which  is  so  necessary  a  ])art  of  the  advanced 
cntro])i()n  o})crati()n.  More- 
over, as  regards  the  inception 
of  the  idea,  Hotz  owes  nothing 
to  the  Greek  surgeon. 

The  first  to  see,  and  i)artly  lo 
supply,  the  second  want — sup 
port  from  below — as  well  as  tlic 
first  to  make  marginal  blepharo- 
])lasty,  was  Spencer-Watson.' 
This  surgeon,  after  splitting  the 
lid  border  as  per  the  old  Greek 
method,  made  as  if  to  remove 
the  ellipse  of  skin,  but  left  the 
outer  end  attached,  as  he  did 
also  the  inner  end  of  tlic  cutan- 
eous bridge  containing  the  cilia, 
as  nourishing  pedicles.  He  then  caused  the  two  fla])S  thus  formed 
to  exchange  places,  and  fixed  them  in  their  new  relations  by  fine 
sutures  (Fig.  141). 

Gayet-  split  the  free  border  and  dissected  up   the  long  strip  of 

skin,  with  external  pedicle, 
which  he  transplanted  back 
of  the  cilia  without  sliding  up 
-;the  skin  containing  them,  thus 
partly  meeting  requirement  (d) 
— or  restoration  of  atrophied 
tissue  (Figs,  142  and  143). 

A  further  improvement  was 
that  made  by  Dianoux"  who, 
in  addition  to  the  bridge  con- 
taining the  lashes,  formed  a 
second  of  integument,  above 
and  adjacent  to  the  first.  The 
two  were  then  transposed  and 


Fig,  140. — Hotz.     Border  fibres  excised. 


[41. — Spencer- Watson 
operation. 


ntropion 


Med.  Times  and  Gaz.,  vol.  xlix,  1874. 
Annal.  d'oculist.  t.  Ixxxii,  1879. 
Annal.  d'oculist,  No.  2,  p.  132,  18S2. 


262 


ENTROPION 


Fig.  142. — Gayet's  entropion  operation. 


sutured.     Both  were  fed  by  double  pedicles,  and  as  soon  as  practica- 
ble those  of  the  intermarginal  strip  were  cut  (Figs.  144  and  145). 

Waldhauer^  made  the 
Jasche-Arlt  operation,  and 
rather  than  throw  away  the 
excised  segment  of  skin,  he 
covered  with  it  the  denuded 
lower  portion  of  the  tarsus — 
graft  without  a  pedicle,  after 
Le  Fort- Wolfe. 

Van  Millingen,-  of  Con- 
stantinople, under  the  name 
of  tarso-chiloplasty,  still 
further  improved  the  methods 
in  question  by  substituting 
for  the  intermarginal  skin  graft  one  of  mucous  membrane  taken 
from  the  inner  lining  of  the  lip.  A  broad  strip  of  this  tissue 
furnishes  the  requirements  mentioned  under  both  {b)  and  {d). 

The  originator  of  tarsoplasty  in  this  connection  w^as  Streatfield.^ 
His  operation  consisted  in  the  removal  of  a  large  horizontal  wedge 
of  tissue  from  the  upper  lid, 


which  was  composed  of  skin, 
orbicularis,  and  a  small  part 
of  the  center  of  the  tarsus.  ,<&- 
No  sutures  were  employed,  ^ 
the  wound  having  been  left  ^-^ 
to  heal  by  granulation  in 
order  to  increase  the  effect 
of  the  operation.  Thus  was 
the  third  requisite  (c)  to  the 
success  of  this  branch  of 
surgery  provided. 

It  occurred  to  Snellen,  of 
Utrecht,     to    combine     this 
guttering  of  the  tarsus  with 
the   Anagnostakis'*    method.         Fig. 
the    only    difference     being 


'  Klin.  Monat.sbl.,  1897,  PP-  47~54- 

2  Oph.  Review,  p.  309,  1887. 

3  Royal  London  Hospital  Reports,  vol.  i,  p. 
■•  Van  Gils  Beitrage,  Utrecht,  1S70,  p.  90. 


-Gayet's  entropion  operation. 
Lid  everted. 


25,  1S5S. 


ENTROPION 


263 


that  double- armed  sutures  were  used,  starling  in,  through,  coming 
back  to  the  lower  skin  flap,  and  tying  over  glass  beads.  Chronis^ 
added  canthoplasty  and,  about  the  same  time,  Agnew  subjoined 
external  tenotomy  or  cantholysis  to  this  procedure,  and  by  these 
means  the  second  requirement  of  (e)  was  obtained. 

Panas-  made  a  similar 
operation  to  that  of  Snellen 
with  two  or  three  highly 
significant  differences,  viz., 
the  careful  dissecting  up  of 
the  lower  skin  flap  as  far 
down  as  possible  not  to  cut 
through  and  make  a  but- 
tonhole, the  passing  the 
sutures  through  the  line  of 
ciha  beneath  the  entire  flap 

(not     through     it),    and    the         Fig.  i44.-Dianoux's  entropion  operation. 

fastening  them  by  collodion  to  the  brow  (Figs.  148  and  149). 
This  dissection  and  the  drawing  up  of  the  lower  flap,  partly  meet 
requirement  (/) .  The  point  wherein  it  fails  of  the  condition  is  the 
fact  that  the  threads  push  the  ciliary  strip  up  instead  of  pulling  it  up 
and  putting  it  on  the  stretch. 

A.  Pagenstecher^  made  an 
incision  just  below  the  upper 
border  of  the  tarsus,  opened 
-  it  up  wide,  exposed  the  tarso- 
orbital  fascia,  which  was 
caught  up  in  a  horizontal 
fold,  and  through  it  were 
passed  the  sutures  that  tra- 
versed the  two  lips  of  the 
cutaneous  incision.  As  a 
complete  operation  for  cntro- 

FlG.  145.— Dianoux's  entropion  operation.       ^j^^^    ^^^    proceeding     fcU    far 

short,  yet  it  served  to  obviate  the  droop  of  the  upper  lid  and  thus 
met  requirement  (g). 

A   resume,   then,  of  the  fundamental  principles  of  the  modern 
operation  for  entropion  of  the  upper  lid,  the  measures  devised  in 

1  Rec.  d'opht.,  1875. 

2  Arch,  d'opht.,  p.  208,  1882. 

3  Klin.  Beob.,  1861 ;  and  A.  f.  Oph.,  xxxvi,  4,  S.  265. 


264 


ENTROPION 


accordance  with  them  and  their  authors  would  stand  something 
Hke  this: 

(a)  Fixed  anchorage  for  sutures  that  hold  up  the  flap  containing 
the  cilia:  the  tarsus  and  the  tarso-orbital  fascia.     Anagnostakis. 

{b)  Support  of  same  from  below:  transplantation  of  tissue. 
Spencer- Watson. 

(c)  Correction  of  incurvation  of  tarsus:  counter-grooving. 
Streatfield. 

(d)  Replacing  of  tissue,  to  atone  for  shrinkage  of  conjunctiva,  and 
to  restore  the  angle  of  the  free  border :  intermarginal  grafts.  Spencer- 
Watson,  Gayet,  and  Van  Millingen. 

(e)  Relief  of  overtension  of  the  lids 
and  accompanying  blepharophimosis: 
canthoplasty,  cantholysis,  and  resec- 
tion of  the  border  fibres  of  orbicularis. 
Chronis,  Agnew,  Hotz. 

(/)  Redressal  of  the  underhang  of 
the  skin  at  the  free  border,  and  the 
turning  up  {not  pulling  tip)  of  the 
cilia :  dissection  of  lower  lip  down  to 
the  cilia.     Panas. 

(g)  Obviation  of  accompanying 
ptosis:  tucking  of  levator  tendon. 
Pagenstecher. 

The  scope  of  any  given  operation 
for  cicatricial  entropion  and  trichia- 
sis of  the  upper  lid  will  be  determined 
by  how  many  of  the  six  features  here 
enumerated  it  will  be  lit  for  it  to  embrace.  To  put  it  another 
way,  the  extent  of  the  surgical  interference  needed  for  the  relief 
of  a  specilierl  case  will  be  governed  by  the  number  of  abnormal 
conditions  that  are  concerned  in  the  i)roduction  or  maintenance 
of  the  entropion  and  the  trichiasis.  If,  for  instance,  only  partial 
absence  of  the  angle  of  the  free  border  is  responsible  for  the 
trouble,  the  simple  insertion  of  an  intermarginal  graft  might 
furnish  the  remedy.  If  entire  absence  and  nothing  more,  a  Hotz 
operation  would  l)e  added  to  this  with,  perhaps,  canthoplasty.  If 
complicated  with  incurvation  of  the  tarsus,  counter-grooving  must 
be  joined  with  the  other  steps,  and  so  on.  As  a  matter  of  fact,  the 
instances  are  exceedintrlv  rare  that  are  not  all  the  belter  for  giving 


groove. 


A(-.E    f)F    SUBJECT 


-^^'5 


one's  pulicnl  ihe  bcncfil  of  ihc  whole  catc.^ory.  For,  if  all  the 
phases  mentioned  are  not  present  in  the  ])articular  case.  o\vin<^ 
to  the  never-ending  progressiveness  of  the  affeclion  on  and  on  for 
years  after  all  apparent  traces  of  the  primary  disease  ha\c  \ani>he(l 
— what  the  several  parts  of  the  operation  do  not  accomplish  in  the 
way  of  actual  cure,  they  will  achie\-e  as  preventives.  Another 
element  that  must  be  taken  into  consideration  in  defming  the  limits 
of  an  operation  for  entropion  of  the  upper  lid,  especially  when  caused 
by  trachoma,  is  the  age  of  the  subject.  Those  who  come  to  us 
suffering  from  this  disorder  represent  c\Try  period  of  life  between 


iW  V 


Fig.  148. — Panas  entropion  opfvalion.  Fic.  149.— I'anas  entropion  operation. 

ten  and  seventy  years.  I  have  known  three  generations  of  a  single 
family  to  be  under  treatment  at  the  same  time.  Naturally,  in  view 
of  the  perpetuity  of  the.  degenerative  changes  of  the  tarsus  involved, 
one  must  strive  for  greater  effect  in  cases  of  children  and  the  younger 
adults  whose  lives  are  before  them  than  in  those  of  the  middle-aged 
and  the  elderly,  if  it  is  hoped  that  the  best  results  of  one's  work  are 
to  endure  till  the  end. 

How  great,  then,  should  be  the  effect  ?  ^lore  than  twenty  years 
of  service  as  surgeon  to  the  Illinois  Charitable  Eye  and  Ear  In- 
firmary, an  institution  whose  outdoor  and  hospital  clientele  com- 
prises some  12,000  new  patients  annually — of  whom  a  large  propor- 
tion were,  a  few  years  ago,  admitted  because  of  entropion  from 


266  ENTROPION 

trachoma — have  given  the  writer  exceptional  opportunities  in  this 
hne  of  surgery,  both  as  participant  and  observer.  Unlike  those 
whom  we  treat  in  private  practice  are  these  wards  of  the  State, 
When  their  troubles  recur  they  come  back  or  are  sent  back  to  us, 
and  it  is  almost  a  daily  occurrence  to  see  one  return  with  an  ag- 
gravated type  of  entropion,  who  a  few  years  before,  had  been 
operated  upon  and  "cured"  of  the  same  trouble  in  the  same  lids. 
It  sometimes  happens,  too,  that  the  recurrence  is  more  pronounced 
than  had  been  the  first  form.  Certainly,  the  difficulties  of  the  second 
attempt  at  restitution  are  in  no  way  lightened  by  what  was  done  at 
the  first.  On  the  other  hand,  it  is  much  to  be  doubted  if  a  well- 
made  operation  for  cicatricial  entropion  has  ever  been  followed  by  too 
great  an  effect.  Many  a  one  has  resulted  in  lagophthalmos  from  un- 
due shortening  of  the  lid,  but  not  from  too  great  an  eversion.  Presum- 
ably this  last  is  possible,  but  it  seems  to  be  only  theoretically  so. 

Wherein  most  operators  fail  is  not  that  they  do  not  obtain  cor- 
rection of  the  deformity,  for  the  merest  tyro  among  them  succeeds 
in  this,  but  that  their  correction  does  not  last.  In  the  pursuit  of  this 
branch  of  plastic  surgery,  therefore,  it  would  not  go  amiss  to  take 
this  as  a  maxim — excessive  immediate  effect  is  necessary  in  order  to 
insure  permanent  correction. 

Technic  of  the  Operation. — The  following  description  em- 
bodies the  author's  conception  as  to  the  surgical  requirements  of 
a  pronounced  cicatricial  entropion  of  the  upper  lid,  and  also  the 
details  of  his  manner  of  procedure.  The  operation  may  be  per- 
formed with  or  without  narcosis.  If  dispensed  with,  cocain  solution 
is  dropped  into  the  conjunctival  sac.  The  infiltration  anesthesia  of 
Sleich  is  effective  in  preventing  pain,  but  the  swelling  of  the  tissues 
it  produces  is  highly  prejudicial  to  nice  results.  The  patient  is 
prone  upon  a  table.  If  both  eyes  are  in  need  of  the  operation  and 
the  patient  can  or  will  submit  to  their  occlusion  for  a  few  days,  it 
is  decidedly  to  his  advantage,  as  to  time,  suffering,  and  inconveni- 
ence, to  make  the  two  operations  in  one  sitting.  One  or  two  trained 
assistants  are  needed. 

First  step.  The  canthotomy  (p.  218).— Free  division  of  the 
external  canthal  ligament  is  indicated. 

Second  step.  Making  of  the  intermarginal  incision  that  is  to 
receive  the  graft.  The  lid  is  grasped,  everted,  and  held  back  by 
the  Beard  lid  forceps  (Fig.  150)  or  by  the  tips  of  the  lingers  placed 
upon  the  eyelashes.     Where  the  latter  exist  in  sufficient  numbers 


ALTOC.KTIIKR 


>67 


and  length,  one  may  dispense  with  the  forceps.  This  inslrumenl 
has  proven  most  serviceable,  as  il  elTcctually  fixes  the  lid  and  pre- 
vents bleeding  while  the  making  of  the  cut  is  in  progress.  The 
scalpel,  with  extra  convexity  near  the  extremity  of  the  blade,  held  as 
shown  in  Figs.  48  and  150,  is  employed.  The  incision  extends  from 
the  outer  limit  of  the  free  border  to,  but  not  including  the  jjunctum. 
Where  manv  fail  is  in  makinu;  this  cut  loo  short  and  loo  shallow. 


Fig.  150. — Making  the  intcr-marginal  incisiun  for  iiiucous  graft. 

If  the  entire  free  border  is  involved  I  do  not  hesitate  to  carry  the 
incision  past  the  punctum,  i.e.  ,  to  the  inner  canlhus.  An  insignih- 
cant  shallow  incision  will  not  retain  the  graft  which,  to  be  effective, 
should  sink  in  till  its  epithelium  is  lower  than  the  surrounding  lid 
margin.  The  position  of  the  incision  is  in  the  posterior  portion  of 
the  substance  of  the  tarsus,  rather  hugging  the  boundary  between 
tarsus  and  conjunctixa;  it  is  four  to  five  millimeters  in  de])lh.  and  is 
made  to  gape  widely  ihat  one  may  judge  of  its  capacity.  The 
lid  is  now  turned  back  inlo  place. 

Third  step.  The  Cutaneous  Incision.— A  broad  lid  spalula  is 
pushed  into  the  up])C'r  fornix  and  lield  by  an  aid  (Plg.  151).  With 
the  same  scalpel  an  incision  is  mafic  ihrough  skin  and  muscle  just 


268 


ENTROPION 


below,  and  parallel  with,  the  upper  border  of  the  tarsus,  except  near 
the  extremities  where  it  takes  a  horizontal  direction,  extending  some- 
what beyond  the  vertical  line  of  the  cantlnis  in  either  direction. 


lHr£RKi/{K^-lHH^lHCI9ION 


:^  w 


l-'iG.  I  SI. — "Alloirclhcr  opL-ration. 


Its  distance  from  the  free  border  varies  witli  the  width  of  the  tarsus. 

Fourth  step.     Dissection  of  the  Flaps.     The  lower  lip  of  the 

incision,  with  its  attaclied  jjortion  of  the  orbicuhiris,  is  Hfled  and 


AT,T()(;i:riii:R 


>6g 


undermined,  and  the  larsiis  cleanly  denuded  down  lo  the  ])()int 
where  the  cilia  are  seen  to  cross  between  it  and  the  muscle,  like 
black  stitches  in  a  seam.  For  this  dissection  it  is  best  lo  use  the 
hack  of  the  knife-point,  and  the  flap  is  thus  loosened  the  entire 
length  of  the  free  border.  When  the  cilia  are  reached,  in  careful 
dissection,  one  feels  the  point  of  the  knife  vil^rate  as  it  chatters  in 
])assing  over  tiiem.  Ikittonholing  at  this  stage  is  to  be  avoided. 
The  U])per  lip  of  tlie  incision,  with  its  underlying  muscle,  is 
loosened  and  ])ushed  u])ward,  so  as  to  exi)()se  tlie  tarso-orbital 
fascia  (Fig.  151). 

Fifth  step.  Resection  of  the 
Border  Fibres  of  the  Orbicularis. — 
The  instruments  are  small,  mouse- 
tooth  forceps  and  delicate,  blunt- 
]3oinled  scissors.  The  upper  edge  of 
the  muscle  clinging  to  the  lower  tlaj) 
is  seized  with  the  forceps  and  neatly 
excised  from  end  to  end  in  one  long 
strip,  the  surgeon  and  the  assistant 
meanwhile  taking  care  of  the  skin 
edge  to  see  that  it  is  not  nicked  an( 
notched. 

Sixth  step.  Counter-grooving  of 
the  Tarsus. — The  operator  steadies 
the  tarsus  on  the  spatula,  notes  the 
line  of  greatest  prominence  of  the 
horizontal  ridge  corresponding  to 
the  gutter  on  the  inner  surface,  and  witli  the  same  scalpel 
incises  it.  The  two  cuts  needed  for  this  purpose  are  so  inclined 
that  they  meet  at  or  near  tlie  ])osterior  surface  of  the  tarsus.  Jf 
the  conjunctiva  should  be  slightly  wounded  in  the  act,  it  is  of  little 
consequence,  though  it  were  better  to  avoid  it.  The  size  of  the 
wedge  w^ill  depend  upon  that  of  the  tarsus.  The  incisions  will,  of 
course,  not  go  far  beyond  the  ridge,  which  is  often  not  so  long  as  the 
tarsus.     The  thickness  of  the  wedge  is  usually  about  two  millimeters. 

Wilder  has  devised  an  apparatus  for  excising  the  wedge  of  tarsus. 
It  consists  of  a  pair  of  small  scalpels  fixed  in  a  holder.  One  move- 
ment suflices  for  the  excision.  The  ai)pliance  is  also  used  by  its 
originator  for  cutting  the  cutaneous  intermarginal  graft  for  restora- 
tion of  tlie  lid  1)or(ler. 


Fig.    152.— Beard's    method 

for 

cntroijion.     The  lieavv  black 

in  OS 

show  ilic  iiK  isions. 

270 


ENTROPION 


Seventh  step.  Inserting  the  Sutures.— One  may  use  the  ordinary 
curved  needles  and  holder  or  Reverdin's  needle  with  handle.  The 
needles  should  be  small,  fine,  and  sharp.  Large  ones  cause  needless 
traumatism.  No.  2,  braided,  black,  silk  thread,  boiled  in  paraffin, 
makes  an  excellent  suture,  of  which  three  are  put  in,  the  first  one 
midway  of  the  tarsus  and  the  other  two,  one  on  either  side  five 
or  six  millimeters  away.     Each  needle  is  passed  from  below,  through 

the  lower  flap  just  far  enough 
from  the  edge  to  insure  a  firm 
hold  for  forty-eight  hours,  then 
through  a  small,  horizontal  fold 
of  the  tarso-orbital  fascia,  picked 
up  in  the  forceps,  just  above  the 
convex  border  of  the  tarsus, 
thence  high  up  beneath  the 
superior  flap,  and  brought  out 
through  the  muscle  and  skin  but 
a  short  distance  below  the  super- 
cilia.  To  make  the  fold  or  tuck 
in  the  fascia,  slightly  dig  the 
needle  into  it  just  where  the 
crest  should  be,  pull  it  up  and 
grasp  the  base  of  the  raised  part 
with  the  mouse-tooth  forceps,  so 
as  to  form  a  horizontal  pleat  and 
pass  the  needle  through,  close 
to  the  jaws  of  the  forceps  (Fig.  154). 

Eighth  step.  Tying  the  Sutures.— Here  the  closest  attention  to 
the  detail  of  every  maneuver  is  of  the  greatest  moment.  The  lips 
of  the  intermarginal  incision  will  now  be  found  tightly  glued  together 
by  fibrin.  They  are  parted  with  the  points  of  the  closed  scissors  and 
all  shreds  cleaned  out.  So,  too,  as  regards  the  flaps  of  the  external 
opening.  They  are  lifted  up,  and  all  blood,  etc.,  removed  from 
under  them,  so  that  they  may  slide  over  tarsus  and  fascia.  The 
central  suture  is  tied  first.  A  double  turn  is  made  in  the  thread  and 
the  lower  end  given  to  the  aid,  while  the  operator  holds  the  upper 
between  thumb  and  index.  The  edge  of  the  lower  lip  of  the  cut 
is  grasped  with  the  mouse-tooth  forceps  near  the  thread  to  be  tied, 
and  drawn  up,  turned  backward  and  placed  in  contact  with  the 
fascia  just  where  the  thread  enters  the  latter,  or  against  the  fold. 


Fig.  153. — Beard's  method  for  entropion. 
Shows  course  of  sutures. 


THE    "altogether"  27I 

simply  pushing  up  tlic  other  flap  with  its  edge  also  turned  backward, 
just  as  described  for  the  ptosis  operation.  While  the  flap  is  being 
thus  held,  the  operator  pushes  down  (or  backward,  as  regards  the  eye) 
with  the  forceps  on  the  weakened  tarsus,  to  make  sure  that  it  bends 
with  its  concavity  outward,  closing  the  newly-made  groove,  and  now 
surgeon  and  assistant  pull  together  on  the  ends  of  thread  and  draw 
it  tight,  when  the  former  takes  both  ends  and  completes  the  knot. 
Were  the  tarsus  not  pressed  down  in  its  middle  this  way,  it  might 
hump  or  buckle  up,  i.e.,  with  its  concavity  downward  and  actually 
increase  the  deformity  it  was  the  aim  to  correct.  The  sutures,  to 
complete  the  canthoplasty,  are  here  put  in  and  tied  as  per  description 
under  "Canthoplasty." 

Ninth  step.  Making  and  Placing  the  Graft. — A  wad  of  cotton 
wet  with  warm  boric  acid  is  laid  over  the  lids.  The  patient's  lower 
lip  is  turned  out  and  gently  washed  with  warm  salt  or  boric  solution 
not  scrubbed  and  rubbed,  so  as  to  hurt  the  epithelium — and  a  small 
cotton  sponge  dipped  in  boric  solution  and  tightly  squeezed  is 
pushed  down  into  the  pocket  between  lip  and  gums.  A  pair  of  large 
straight  scissors,  the  same  as  are  used  for  the  canthotomy,  answer 
best  for  cutting  out  the  graft.  The  lip  is  caught  between  the  thumb 
and  index,  rolled  over  the  medius  so  as  to  evert  well,  the  scissors 
opened  very  wide,  the  base  of  the  blades  placed  firmly  on  that  part 
of  the  mucous  membrane  that  usually  lies  opposite  the  margins  of  the 
gums  and,  bearing  down  with  the  scissors  while  holding  up  with  the 
middle  finger  from  below,  a  long  ellipse  is  excised  with  one  snip  of  the 
shears  that  will  fill  the  intermarginal  incision.  The  piece  will 
include  not  only  the  entire  thickness  of  the  mucous  membrane,  but 
a  number  of  lobules  of  adipose  tissue  will  be  found  attached  to  it. 
Turn  it  over,  face  down,  upon  the  nail  of  the  left  thumb  (or  upon  the 
rubber  glove  or  gauze  cot  covering  the  same)  and  with  the  small 
scissors,  carefully  trim  off  all  the  adipose,  paring  it  down  to  the 
submucous  connective  tissue. 

A  very  thin,  flabby  graft  is  useless.  It  must  have  body  as  well 
as  breadth.  In  respect  to  the  latter  dimension,  as  time  goes  on, 
I  am  inclined  to  make  the  grafts  wider  than  of  yore.  In  extreme 
cases,  they  would  measure  hardly  less  than  seven  or  eight  millimeters 
at  the  middle. 

Rinse  it  in  i%  salt  or  4%  boric  acid  solution  at  about  110°  F., 
and  place  it  flatwise  in  the  cut  back  of  the  cilia,  making  sure  that 
the  epithelial  surface  is  outward.     The  tips  of  tiny  spindle-shaped 


272 


ENTROPION 


cotton  sponges  are  well  wrung  out  of  boric  solution  and  applied 
about  the  edges  of  the  graft,  to  drink  up  the  slight  oozing,  the 
lid  being  all  the  time  held  everted  as  (h'rccted  for  making  the  mar- 
ginal cut. 

The    graft    must  be  am])le    in  exactly  the  same  proportion  as 

is  the  intermarginal  incision.  If 
the  first  piece  excised  falls  short 
of  filling  the  cut,  it  is  better  to 
take  a  second,  suflkiently  large, 
to  piece  out,  squaring  and  butting 
together  their  ends. 

No  decided  hemorrhage  should 
be  taking  place  from  the  wound 
when  the  graft  is  laid  in,  else  a 
clot  will  form  beneath  and  inter- 
fere with  proper  union.  But  a 
slight  bleeding,  which  is  always 
checked  by  laying  in  the  graft, 
is  an  advantage  in  that  it  helps 
to  fix  and  to  hold  the  morsel  in 
position.  Sutures  would  be  both 
useless  and  harmful,  as  when 
quickly  put  in  (i.e.,  not  fussed 
with  too  much)  and  stuck  by 
fibrin,  there  is  no  possibility  of  the  graft  letting  go,  except,  possi- 
bly, in  removing  the  dressing  (Fig.  154). 

The  latter  consists,  first,  in  the  usual,  thin  layer  of  cotton  wet 
with  warm,  boric  acid  solution,  carefully  applied  to  the  closed  lids 
(p.  15).  There  is  a  little  point  of  considerable  value  that  might 
be  mentioned  in  this  connection;  after  every  other  operation  treated 
of  in  this  volume,  except  the  one  now  under  discussion,  the  ap- 
plication of  the  first  wet  sheet  of  cotton  is  made  by  sliding  it  on  to 
the  lids  from  above,  in  order  to  smooth  the  lashes  downward  (see 
dressing  after  "Extraction").  In  this  instance  the  reverse  obtains, 
viz.,  it  is  slid  upward,  for  the  reason  that  the  primary  effect  of  this 
operation  is  to  turn  the  cilia  upward,  like  the  feathers  in  a  strutting 
peacock's  tail,  and  such  a  manipulation  of  the  dressing  tends  to 
heighten  the  result.  To  avoid  loss  of  time  in  the  first  removal  of 
the  dressings,  caused  by  prolonged  soaking  of  the  cotton,  as  well  as 
to  ])rcvcnt  loss  of  the  graft   itself,   through  having  become  glued 


Sliows  conipk-lL-d  operation. 


MUCOUS    OR    SKIN    CRAFTS  273 

firmly  to  the  cotton,  one  may  place  next  to  the  lids  a  piece  of  thin 
soft  gutta  pcrcha  tissue.  Upon  this,  a  good-sized  ])ad  of  dry 
cotton  is  built  up  and  over  all  the  wet  netting  roller  is  applied. 
The  patient  is  ke])t  quiet  in  bed  for  forty-eight  hours,  when  the 
bandage  is  cut,  the  cotton  removed  by  soaking  with  warm,  boric 
acid  solution  and  all  the  sutures  are  removed.  The  identical 
dressing  is  reapplied  with  renewal  at  twenty-four  iiour  intervals 
for  a  week  or  more.  It  will  not  do  to  leave  off  the  bandage  earlier, 
else  the  drying  effect  of  exposure  will  cause  the  graft  to  perish  and 
drop  out.  Even  after  the  final  removal  of  the  bandage,  it  is  well  to 
keep  the  graft  covered  for  a  few  days  with  a  film  of  sterilized  vaselin 
for  fear  of  desiccation.  Formerly  the  wound  in  the  mouth  was 
closed  by  sutures,  but  of  late  nothing  is  done  for  it.  It  heals  kindly 
by  granulation  and,  moreover,  most  of  the  subjects  are  operated 
without  narcosis,  and  are  glad  to  be  spared  further  "sewing." 

Conclusions. — In  my  practice  the  several  procedures  just 
described,  viz.,  canthoplasty,  Hotz's  method,  counter-grooving  of 
the  tarsus,  tucking  of  the  tarso-orbital  fascia,  and  the  insertion  of 
the  post-ciliary  mucous  graft  are  nearly  always  combined  in  a 
single  operation,  which  at  the  Eye  and  Ear  Infirmary  has  come 
to  be  known  as  "the  altogether."  They  are  thus  united  not  for 
convenience,  but  because  experience  has  taught  that  by  so  doing 
the  efi"ect  is  greater,  better,  and  more  lasting.  If  the  same  were 
done  piecemeal,  i.e.,  for  instance,  first  the  canthoplasty,  the  Hotz 
operation  a  week  later,  and  so  on,  the  ultimate  result  would  be 
much  less  satisfactory.  Each  of  the  multiple  factors  concerned  in 
the  entropion  is  attacked  by  an  efiicient  foe  and  the  defects  are 
righted  in  a  rational  w^ay  by  judiciously  apportioning  the  efi'ect 
among  the  several  ills,  rather  than  by  giving  too  great  prominence 
to  one  or  two  (Figs.  155  and  156). 

With  regard  to  the  choice  qf  mucous  or  of  skin  grafts  for  the  restor- 
ation of  the  free  border,  ophthalmic  surgeons  are  not  in  accord. 

Knapp^  prefers  those  of  skin,  claiming  that  it  is  the  more  suit- 
able, inasmuch  as  the  normal  lining  of  the  free  border  is  dermal 
and  not  mucous.  If  one  will  take  the  pains,  however,  to  ex- 
amine a  few  lids  that  have  been  subjected  to  the  operation, 
he  w^ill  be  readily  convinced  that  the  graft  after  a  comi)aratively 
short  time,  really  takes  the  place  of  conjunctiva  in  that  it  lies  in 
contact  with  the  cornea. 

1  De  Schweinitz,  Diseases  of  the  Eye. 
18 


274 


ENTROPION 


Others  have  urged  as  an  objection  to  the  mucous  graft,  that  its 
shrinkage  is  greater  than  one  of  skin.  Such  does  not  agree  with  my 
observation.  Indeed,  an  extended  experience  with  grafts  of  the 
three,  recognized  varieties,  viz.,  those  of  Wolfe,  Thiersch,  and  Van 
MiUingen,  have  led  me  to  believe  that  the  last  are  precisely  those 
that  retain  more  nearly  their  original  bulk,  and  for  the  past  ten  or 
twelve  years,  I  have  resorted  to  "chiloplasty."  The  last  bit  of  skin 
I  made  use  of  to  replace  the  border  was  put  into  that  of  the  lower 
lid  where  it  lay  in  contact  with  the  globe.  Very  soon  an  ugly  ulcer 
appeared  on  the  cornea  immediately  under  the  graft.  Although 
not  a  hair  could  be  found  in  the  patch  to  cause  the  irritation,  the 


Fig.  155. — The  expression  of  face  bcfi 


altogether  operation." 


ulcer  persisted  in  spite  of  treatment.  Finally  it  was  remarked,  in 
everting  the  lid,  that,  while  the  surrounding  conjunctiva  was 
normally  moist,  the  graft  itself  remained  perfectly  dry.  This  led 
to  the  conclusion  that  the  oily  nature  of  the  epidermis  was  a  hin- 
drance to  proper  lubrication,  hence  the  ulcer.  The  piece  was 
excised,  a  graft  from  the  lip  substituted,  and  at  once  the  ulcer 
healed. 

The  more  thoroughly  the  various  steps  of  the  operation  have 
been  performed  the  uglier — from  a  purely  cosmetic  standpoint — 
are  its  early  results.  In  a  few  cases  so  pronounced  has  been  the 
ectropion,  that  a  crust  has  formed  on  I  he  ])alpebral  conjunctiva 
from  exposure  lo  llie  air.  This,  with  llic  large  red  grafts  and  the 
inverted  lashes,  all  go  to  make  a  ])iclure  not  overly  attractive,  yet, 


GREEN  S    OPKkA 


275 


as  before  stated,  I  ha\c  nc\cr  seen  peTiiiaiu'nt  hypcTcorrc'Clion. 
But  a  short  while  and  all  iinsi,u;luliness  disa])|)cars. 

Operation  of  Green  for  Entropion  (Trans.  Anur.  Ojihlh. 
Soc,  1880,  Vol.  Ill,  p.  167). — Dcscrifjlion  hy  Wilder  in  Wood's 
"System  of  Ophthalmic  Operations." 

This  operation  is  intended  by  its  author  for  those  cases  of  cica- 
tricial entropion,  occurring  in  trachoma,  in  which  there  is  marked 
incurving  and  a  furrow  on  the  conjunctixal  side  of  the  tarsus.  It  is 
done  in  three  stages: 


Fig.  156. — The  expression  of  face  ten  days  after  "  the  altogether  operation." 

First  Stage. — The  upper  lid  is  held  firmly  everted  with  the  fingers. 
With  a  round-pointed  scalpel  an  incision,  parallel  to  and  2  mm.  from 
the  row  of  openings  of  the  Meibomian  glands,  is  made  through  the 
tarsus,  in  extreme  cases  extending  from  near  the  inner  to  the  outer 
canthus.  This  incision  (Fig.  157)  is  carried  through  the  entire 
thickness  of  the  tarsus,  but  does  not  extend  into  the  muscular  layer, 
as  in  the  operation  of  Burow. 

Second  Stage. — The  lid  is  then  replaced  and  a  strip  of  skin  not 
exceeding  2  mm.  in  width  is  excised  from  the  anterior  surface  of  the 
lid.  The  lower  lashes,  and  the  tissue  removed  should  be  only  skin 
and  connective  tissue,  leaving  the  muscle  intact. 

Third  Stage. — -Fine  silk  sutures,  armed  with  small  curxed  needles, 
are  passed  as  follows:  A  needle  is  introduced  at  the  edge  of  the 
lid,  just  behind  the  row  of  eye  lashes,  and  brought  out  just  within 
the  wound  in  the  skin.      The  needle  is  then  reintroduced  into  the 


276 


ENTROPION 


upper  border  of  the  skin  wound,  passed  deeply  backward  and 
upward  to  graze  the  anterior  face  of  the  tarsus,  and  brought  out 
I  cm.  or  more  al)o\e  the  point  of  entrance.  Three  such  sutures 
are  passed  and,  when  tied,  not  only  strongly  evert  the  ciliary 
border,  but  close  the  skin  wound.  The  lashes  are  held  in  the 
everted  position  by  collodion  applied  to  them  until  the  widely  gap- 
ing wound  in  the  tarsus  has  nearly  healed,  as  it  does  by  granulation. 
Ewing  ipphthal.  Record,  October,  1907,  p.  490)  modifies  this 
operation  in  an  important  way,  endeavoring  to  partially  fill  in  the 
gap  in  the  tarsus  by  means  of  conjunctiva. 


Fig.   157. — Green's  operation  for  entropion. 

Beginning  at  the  posterior  margin  of  the  free  border  of  the  lid, 
he  dissects  back  the  conjunctiva  from  the  tarsus  to  a  distance  of -4 
or  5  mm.  along  the  whole  length  of  the  lid.  (This  seems  to  be  a 
detail  of  some  difficulty,  because  of  the  intimate  relation  of  the  tarsus 
and  conjunctiva.) 

Retracting  the  conjunctival  flap,  he  makes  an  incision  through 
the  tarsus  exactly  as  in  the  Green  operation.  To  aid  the  assistant 
in  strongly  everting  the  ciliary  border  during  the  placing  of  the 
sutures,  he  introduces  a  temporary  stitch  in  the  surface  of  the  tarsus, 
so  that  traction  on  it  will  cause  the  tarsal  wound  to  gape  widely,  as 
in  P1g.  1 58.  For  the  upper  lid.  seven  or  eight  fine,  double-armed  loop 
sutures  are  then  introduced;  for  the  lower  four  or  five  suffice  (Fig. 
159).     The  needles  are  first  passed  about  2  mm.  ai)arl,  through  the 


GREEN  S    OPERATION 


•77 


edge  of  the  conjunctival  flap  which  was  dissected  back;  then  through 
the  bottom  of  the  wound,  back  of  the  tarsus  bearing  the  cilia,  to 
emerge  on  the  skin  just  back  of  the  cilia.  For  convenience  in  remov- 
ing the  sutures  and  to  prevent  them  from  cutting  too  deeply  into  the 
skin,  all  the  stitches  are  tied  over  a  fairly  large  No.  12  strand  of 
catgut,  placed  along  the  edge  of  the  lid,  thus  making  a  kind  of  quill 
suture.  Tightening  the  sutures  draws  the  conjuncti\-a  into  the 
wound  and  strongly  exerts  the  edge  of  the  lid. 


Fig.  158. — Ewing's  modifuation  of  Green's  operation. 

A  serious  and  not  infrequent  sequel  of  operations  for  cicatricial 
entropion  from  trachoma  is  ulceration  of  the  cornea.  This  occurs 
even  in  cases  that  had  previously  escaped  this  complication.  ]\Iore- 
over,  these  ulcers  are  apt  to  be  centrally  located,  just  where  they 
can  do  most  harm  to  the  \ision,  and  heal  least  readily.  One  can- 
not, therefore,  use  too  many  ])recaulions  with  the  \ie\v  to  their 
prevention;  first,  as  to  the  choice  of  the  case — never  one  in  which 
the  trachomatous  process  is  still  active;  second,  as  to  the  preparation 
of  the  eye — make  copious  irrigation  of  the  conjunctival  sac  with 
warm  mild  antiseptics  immediately  beforehand;  third,  as  to  the 
operation  itself — not  needlessly  to  injure  the  corneal  epithelium 
by  such  things  as  too  much  cocain,  broad   spatula,  or  lid-clamj)s. 


278  ENTROPION 

nor  by  going  Ihrough  the  entire  thickness  of  the  lid  with  the  needles, 
thus  pricking  the  cornea  or  leaving  a  loop  of  thread  where  it  will 
rub  that  membrane.  The  effect  of  the  free  and  prolonged  instillation 
of  cocain  solution  is  unquestionably  wrong  in  that  it  results  in  the 
drying  and  exfoliation  of  the  corneal  epithelium.  A  very  few  drops 
before  beginning  the  operation  is  sufficient,  and  it  should  be  seen  to 
that  the  eye  is  flooded  from  time  to  time  with  warm  boric  solution. 
An  additional  safeguard  would  be  the  instillation  of  a  few  drops  of  a 
25  to  50%  solution  of  argyrol  when  about  to  apply  the  final  dressing. 
This  preparation  is  not  only  an  effective  antiseptic,  but  it  is  otherwise 
harmless,  and,  besides,  has  the  property  of  remaining  in  the  con- 
junctival sac  for  several  days. 


Fig.  I  =59. — E wing's  operation  for  entropion. 

ORGANIC  ENTROPION. 

LOWER    LID. 

Cicatricial  entropion  of  the  lower  lid  does  not  lend  itself  so  well  to 
the  surgical  methods  described  in  connection  with  that  of  the  upper. 
Here  the  conditions  are  different.  The  transformation  of  the  tarsus, 
the  absence  of  the  width  of  the  free  border,  disappearance  of  its 
posterior  angle,  etc.,  do  not  figure  so  prominently  as  in  the  other  case. 
Lid  tension,  the  tension  of  the  border  fibres  of  the  orbicularis,  strain 
of  the  shrunken  conjunctiva,  and  the  blepharophimosis  are  the  things 
chiefly  to  be  contended  against.  These,  together  with  the  anatomi- 
cal peculiarity  of  the  inferior  tarsal  plate— that  is,  in  being  only 
about  one-half  the  witlth  of  the  superior  one— necessitate  a  mode  of 


METHODS    OF    IWXAS    AXI)    {'.RAF.rK 


279 


handling  quite  special.  It  is  true,  ho\ve\er,  thai  absence  of  the  free 
border  occasionally  constitutes  the  main  fault,  and  the  i)lacing  of 
an  intermarginal  graft  the  best  remedy. 

The  prime  indications  are  to  release  the  lid  from  the  binding 
pressure  of  the  contractile  and  shrinking  tissues,  by  resection  of 
the  border  fibres  of  the  orbicularis,  by  canthoplasty  with  cutting 
of  the  external  canthal  ligament,  and  by  piecing  out  the  conjunctiva 
with  grafts  of  skin  or  mucous  membrane.  These  measures  may,  in 
occasional  instances,  be  supplemented  by  the  judicious  employment 
of  operations  for  the  shortening  of  the  adjacent  integument. 


Fig.  160. — Panas'  operalion  for 
entropion. 


Fig.  161.^ — Graefe's  operation  for  entropion. 


Among  the  best  of  these  is  that  of  Panas^  (Fig.  t6o).  The 
resulting  cicatrix  corresponds  to  the  natural  topography  of  the 
region.  It  is  executed  as  follows:  two  vertical  incisions,  each  about 
one  centimeter  long,  are  made  through  skin  and  muscle,  one  near 
the  outer  canthus,  the  other  near  the  inner,  their  upper  extremities 
close  under  the  cilia.  Their'jower  ends  are  joined  by  a  horizontal 
incision  through  skin  only.  The  flap  thus  outlined  is  dissected  up 
to  the  very  roots  of  the  eyelashes,  everted  and  a  strip  of  the 
premarginal  fibres  of  the  orbicularis  is  excised.  A  parallelogram 
is  trimmed  from  the  lower  edge  of  the  loosened  flap,  its  width 
proportional  to  the  amount  of  shortening  demanded,  and  the  open- 
ing closed  by  fine  sutures. 

V.  Graefe  gave  a  method  that  has  often  done  good  service  (Fig. 
161).     Three  millimeters  from  and  parallel  with  the  free  border, 

1  Mem.,  These  de  Paris,  1873. 


280  ECTROPION 

an  incision  is  made  through  skin  and  muscle,  extending  nearly  the 
entire  length  of  the  lid.  A  triangle  of  skin,  whose  base  rests  on  the 
middle  of  the  first  incision,  and  whose  size  is  governed  by  the  degree 
of  effect  aimed  at,  is  excised — muscle  not  included.  The  strip 
of  skin  and  muscle  lying  next  to  the  margin  are  caught  with  forceps 
and  dissected  from  the  tarsus  until  the  cilia  are  exposed,  taking 
care  not  to  buttonhole,  and  the  attached  fibres  of  muscle  removed 
with  scissors.  The  two  corners  of  skin  are  undermined  and  the 
whole  opening  closed  by  small  sutures.  If  still  greater  effect  is 
wanted,  a  triangular  piece  of  the  tarsus  may  be  excised,  base  down- 
ward, or  in  the  opposite  direction  to  that  of  the  skin  triangle  (see 
dotted  lines  in  accompaning  cut). 

The  curious  operation  for  entropion  of  the  lower  lid  that  bears 
the  name  Flarer-Stellwag^  was  made  by  "scalping"  the  lid,  turning 
the  abscinded  strip  upside  down  and  replanting  it. 

ECTROPION  AND  BLEPHAROPLASTY. 

The  name  ectropion  which  is  the  exact  opposite  of  entropion, 
refers  to  an  eversion  or  turning  outward  of  the  lid,  either  partial 
or  total.  The  degree  of  eversion  varies  between  that  slightest  of 
all  partial  forms,  wherein  the  lower  punctum  loses  its  suction  on 
the  globe  by  the  merest  separation  therefrom,  to  that  most  extreme 
of  total  ectropion,  where,  through  extensive  destruction  of  the  in- 
tegument surrounding  the  palpebral  fissure  and  the  subsequent 
contraction,  both  tarsi  are  not  only  inverted,  but  drawn  widely 
asunder  so  as  to  expose  the  entire  area  of  the  conjunctival  sac. 

For  convenience,  we  may  separate  the  varieties  of  ectropion  into 
four  grand  divisions,  which,  given  in  the  inverse  of  theii:  importance 
or  frequency  are,  (a)  Spastic,  (b)  ^Mechanical,  (c)  Atonic,  and  (d) 
Cicatricial. 

Spastic  ectropion,  muscular  ectropion,  acute  ectropion, 
arc  several  names  that  denote  the  same  condition,  and  alTcct 
mainly  the  lower  lid.  Spastic  ectropion  has  its  beginning  in  some 
sudden  swelling  of  the  conjunctiva  or  advancement  of  the  globe  that 
tends  to  push  forward  the  free  or  straight  border  of  the  tarsus.  At 
the  same  time  the  backward  pull  of  the  orbicularis,  through  normal 
contraction  upon  the  convex  border,  together  with  the  continuance 
of  the  outward  push  of  the  border,  completes  the  eversion  by  over- 

1  Flarcr:Renexioni  sulla  trichiasi,  etc.  Milano,  1828.  Stellwag,  v.c. : 
Ein  neues  Vcrfahren  gegen  einwiirtsgekchrte  Wimpcrn.  Allgcm.  Wr. 
med.  Ztg.,  1883,  Nr.  49. 


MECHANICAL    AXD    CICATRICIAL  251 

coming  the  action  of  the  marginal  fibres.  'J'lie  eclroi)ion  once  ac- 
complished, the  latter  llbres  only  serve  to  maintain  it.  This  condi- 
tion, when  exaggerated,  may  be  termed  blepharo-jjaraphimosis. 

Mechanical  ectropion  is  really  a  less  acute  form  of  the  above, 
in  which  both  lids  may  be  involved,  and,  in  cases  of  long  standing,  is 
characterized  by  structural  changes  in  all  the  tissues  of  the  lids, 
but  more  ])articuhirly  the  innermost.  The  active  force  is  referable 
to  exophthah-nos,  ectasia  of  the  globe  from  staphyloma,  tumors,  etc., 
or  to  growths  and  chronic  swellings,  hypertrophy,  etc.,  of  the  con- 
junctiva {mucous  ectropion).  The  perverted  action  of  the  or])icu- 
laris,  alluded  to,  figures  here  also. 

Atonic  ectropion  chiefly  concerns  the  lower  lid,  and  may  be  due 
to  (a)  paralysis  or  paresis  of  the  orbicularis — paralytic  ectropion — or 
(b)  relaxation  of  all  the  tissues  of  the  lid,  with  lengthening  of  the 
free  border — senile  entropion.  As  a  complication  of  this  form, 
hypertrophic  conjunctivitis  of  the  lower  lid  and  epiphora  occur,  and 
can  easily  be  mistaken  for  a  purely  mucous  ectropion. 

Cicatricial  Ectropion. — In  this  variety,  the  eversion  is  the  in- 
direct result  of  a  burn,  other  injury,  or  disease  that  destroys  all  or  a 
part  of  the  skin  of  the  lids.  The  destruction  that  causes  ectro])ion 
rarely  extends  deeper  than  the  superficial  fascia,  or,  at  most,  the  orbic- 
ularis. When  the  deeper  leaf,  viz.,  the  tarsus  and  conjunctiva, 
is  carried  away,  that  is  another  affair.  The  principal  agents  in 
bringing  about  the  condition  are  the  contraction  of  the  scar  and, 
after  the  eversion  is  pretty  well  established,  the  anchylosis  in  the 
external  sulcus.  The  location  and  extent  of  the  scar  will  determine 
those  of  the  ectropion. 

As  to  the  surgical  means  adopted  for  the  correction  of  ectropion, 
they  will  depend  mainly  upon  the  nature  of  the  defect.  For  the 
purely  spastic  kinds,  it  will  ordinarily  suffice  to  remove  that  which 
is  most  active  in  producing  it.  Treatment  of  the  conjunctivitis, 
or  whatever  the  cause,  putting  on  strips  of  adhesive  plaster 
to  keep  the  palpebral  fissure  closed,  and  bandaging,  if  the  condi- 
tions will  admit  of  this.  If,  however,  there  is  strangulation  from 
the  muscle-cramp,  an  immediate  canthotomy  (p.  21 8)  with  free 
cutting  of  the  external  canthal  ligament  is  needed.  For  the  mechan- 
ical form,  as  in  the  spastic,  attention  to  the  ulterior  cause  is  often 
the  sole  means,  be  it  the  ablation  of  anterior  staphyloma,  the  re- 
moval of  a  tumor  of  the  globe,  tarsus  or  conjunctiva,  or  the  relief 
of  a  transient  exophthalmos.     Should  it  be  from  a  more  lasting  but 


282 


ECTROPION 


benign  and  reducible  exophthalmos,  median  tarsorrhaphy  would  likely 
be  the  most  eligible  recourse  (p.  223).  Mucous  ectropion  of  the 
lower  lid  will,  in  most  instances,  yield  to  local  medical  treatment, 
together  with  adhesive  or  collodionized  strips  to  support  the  lid, 
and  bandaging.  Failing  in  this,  one  would  far  better  try  one  of  the 
simpler  surgical  procedures,  such  as  the  insertion  of  a  Snellen^  suture, 

rather  than  the  emlopy- 
ment  of  more  radical 
measures,  or  resort  to  such 
irrational  and  primitive 
methods  as  cauterization 
or  excision  of  the  offending 
conjunctiva. 

An  excellent  means  of 
holding  up  a  sagging  lower 
lid  for  an  extended  period, 
as  well  as  for  the  better 
closure  of  the  palpebral 
fissure  in  certain  cases  of 
lagophthalmos,  is  by  the 
use  of  the  contrivance  in- 
vented by  the  writer  for  the 
coaptation  of  shin-wounds 
in  general  surgery. - 

This  consists  of  a  strip  of 
tarlatan  ribbon,  near  one 
selvage  of  which  is  attached  a  row  of  tiny  flattened  hooks,  similar  in 
shape  to  those  employed  in  connection  with  ''eyes."  -A  strip  of 
this  is  fastened,  by  flexible  collodion,  hooks  up,  to  the  lower  lid; 
and  another,  hooks  down,  to  the  brow.  The  two  are  then  laced, 
with  a  suitable  cord,  the  lids  approximated  as  nearly  as  desired, 
and  the  cord  tied  in  a  bowknot. 

The  Snellen  Suture.— A  No.  2  braided  thread  of  silk,  boiled  in 
paraffin  and  armed  with  two  curved  needles,  is  gotten  ready. 
The  eye  is  cocainized.  The  needles  are  passed  down  into  the  most 
prominent  fold  of  the  exposed  conjunctiva,  obliquely  through  the 
tarso-orbital  fascia,  at  its  junction  with  the  tarsus,  on  down  and 
forward  to  emerge  from  the  skin  opposite  the  rim  of  the  orbit 

Wan  Gils  Beitrage,  p.  90,  Utrecht,  1870. 

2  Described  in  a  paper  read  before  the  Chicago  Medical  Society,  and  i)ub- 
lished  in  the  Medical  Recorder  for  June,  1903. 


Fig.  162. — Snellen's  suture  for  ectropion. 


VF.RIIOEFF  S    SU'ITRK 


'83 


(Fig.  162).     They  cnlcr  about  one-half  centimeter  apart,  and  their 

courses  very  sHghtly  diverge.     Two  or,  at  most,  three  such  sutures 

are  placed  and  each  pair  is  tied  over  a  cylinder  of  gauze  or  tubing.     The 

tension  put  upon  them  is  just  sufficient  to  cause  a  slight  entropion. 

They  are  left  in  for  several  weeks 

or  until  suppuration  appears  around 

them,    the    eye    being    meanwhile 

bandaged,  with  daily  renewal  and 

cleansing.     Silver  w^ire  is  preferred 

to   that   of   silk   by  a   number   of 

surgeons,     the    assumption    being 

that  the  metal  is  better  tolerated. 

I  think,  however,  that  if  the  silk  is 

thoroughly    boiled    in   paraffin,   so 

that   it  will  not  act  like  an  open 

path  for  the  entrance  of  bacteria, 

that  it  will  be  found  superior  to  any 

other  material. 

Verhoeff's  Suture  and  Button 
Operation. — -While  attending  the 
last  (1913)  meeting  of  the  American 
Ophthalmological  Society,  Verhoeff , 
of  Boston,  described  to  me  a  meas- 
ure he  had  just  devised  for  such  forms  of  ectropion  as  the  atonic  and 
the  mucous.  It  seemed  so  well  conceived  that,  immediately  upon 
coming  home,  I  tried  it,  and  with  most  gratifying  results.  The 
technic  is  briefly  as  follows: 

A  rather  long,  and  slightly  curved,  needle,  armed  with  No.  2, 
braided  silk,  is  passed  through  the  skin,  beginning  at  a  point  3  or  4 
mm.  above,  and  twice  as  far  to  the  temporal  side  of,  the  outer  com- 
missure (Fig.  164).  It  is  pushed  along  beneath  the  skin,  parallel 
with  the  margin  of  the  lower  lid,  and  not  more  than  3  mm.  from  the 
line  of  cilia,  as  far  as  its  length  will  conveniently  permit.  It  is  then 
brought  out,  and  reinserted  through  the  same  hole  at  which  it 
emerged.  It  is  worked  farther  along,  again  brought  out,  etc.,  till 
it  reaches  the  point  just  above,  and  internal  to,  the  inner  commissure, 
which  corresponds  to  that  where  it  was  first  introduced.  (See 
dotted  lines  in  drawing.)  It  is  here  brought  out  and  passed  upward 
through  one  of  the  two  holes  of  an  ordinary,  pearl  shirt-button,  and 
downw^ard  through  the  other;  after  which  it  is  made  to  go  back,  in 


VrgvU-Rolx-rtson  suture  for 
ectropion. 


284 


ECTROPION 


the  same  manner,  but  by  a  route  about  3  mm.  farther  from  the  lid 
margin. .  Both  ends  of  thread  arc  then  passed  upward  through  the 
holes  in  another  button,  and,  after  having  been  sufficiently  drawn  up, 
are  tied  in  a  bow-knot.  When  it  comes  to  the  second  dressing,  if 
there  is  undue  tension  upon  the  suture,  it  may  be  relaxed  by  undoing 
the  bow  and  letting  out  the  thread.  On  the  contrary,  if  the  suture 
is  too  slack  it  may  be  drawn  tighter.  Indeed,  its  tension  may  be 
modified  at  any  time  as  long  as  it  is  left  in  place.  This  will  be 
from  two  to  three  weeks.  It  is  not  the  intention  to  have  the  thread 
cut  through  the  lid,  nor  to  cause  suppuration,  as  in  some  of  the  old 
ligatures.     It  does  give  rise  to  a  certain  amount  of  scar  tissue  which 


Fig.  164. — Verhoeff's  suture  and  button. 

together  with  the  firmness,  and  length  of  time  it  holds  up  the  \k\, 
brings  about  the  cure. 

Argyll-Robertson^  devised  a  knot  which  he  used  in  conjunction 
with  a  lead  plate.  The  needles  of  a  double-armed  suture  were 
passed  from  in  front,  through  the  whole  thickness  of  the  lid,  eacli 
one  about  six  or  seven  millimeters  from  the  middle  line,  and  two 
millimeters  from  the  border.  Then  carried  free  over  the  conjunc- 
tiva and,  entering  at  the  bottom  of  the  cul-de-sac,  were  brought 
out  on  the  cheek  some  thirty-two  millimeters  below  the  lid  margin. 

1  E(linl)urL;li  Clinical  and  Pathological  Journal,  1S83. 


FUKALA  S    SUTURK 


285 


Fig.   165. — Fukala's 
suture  for  ectroi)ion  of 


ncision  and 
le  lower  liii. 


Before  tying  the  ends  over  tubing  a  lead  j^latc  (25  x  6  x  i  milli- 
meters), with  ends  and  corners  smoothly  rounded,  was  slid  beneath 
the  threads  lying  on  the  conjunctiva.  The  objecl  of  the  ])lale  was 
to  straighten  the  out-curve  of  the  tarsus 
and  the  infold  of  the  fascia  resulting 
from  the  ectropion  (Fig.  163). 

Fukala^  is  the  author  of  a  combined 
suture  and  incision  operation  that  has 
met  with  approbation.  Jaeger's  lid 
spatula  is  put  into  the  lower  fornix 
and  an  incision  made  through  skin 
and  muscle,  down  to  the  tarso-orbital 
fascia,  ten  to  twelve  millimeters  from 
the  free  border,  parallel  with  it,  and 
somewhat  longer  than  the  palpebral 
llssure.  The  upper  flap,  with  its 
muscle,  is  undermined  up  to  the  cilia 
and  the  fascia  is  exposed.  Three 
sutures  are  introduced  as  follows: 
the  needle  is  passed  through  loosened  skin  and  muscle  four 
millimeters  or  more  from  the  border,  thence  carried  upward, 
between  muscle  and  tarsus,  and  passed  straight  through  to  the  con- 
junctival surface,  close  up  to  the  cilia.  It  is  taken  back  the  same 
route,  only  three  millimeters  away.  One  thread  is  placed  in  the 
center  and  one  near  either  canthus  and  tied  over  sections  of  tubing. 
In  closing  the  incision  with  interrupted  sutures  they  are  made  to 
dip  in  and  out  of  the  tarso-orbital  fascia,  much  after  the  manner  of 
those  used  in  Hotz's  operation  for  entropion.  The  chief  feature 
is  the  doubling  of  the  skin  flap  upon  itself  (Fig.  165).  Angelucci- 
makes  a  similar  operation  in  all  save  that  no  sutures  are  used. 
Atonic  ectropion,  whether  the  result  of  actual  paralysis  of  the  or- 
bicularis or  from  a  senile  atrophy  and  relaxation  of  the  tissues  of 
the  lid,  requires  practically  the  same  surgical  treatment,  though 
the  age  of  the  subject,  and  the  j)rospect  of  a  cure,  as  in  the  case  of 
certain  paralyses  of  the  seventh  nerve,  would  have  a  tendency  to 
qualify  the  means. 

Three  dominant  principles  underlying  most  of  the  operations 
that  have  been  undertaken  for  this  variety  of  ectroj)ion,  are:   (i) 

1  Berliner  klin  .Wocli.,   i8gi,  S.  287. 
-  Rev.  gen.  d'Ojjht.,   i8g8,  Xo.  9. 


286 


ECTROPION 


shorlening  the  free  border  by  excision  of  a  wedge  therefrom,  (2)  the 
l)ushing  up  and  shortening  by  means  of  sliding  flaps  and  excision  of 
a  triangle  of  skin  at  the  external  canthus,  and  (3)  the  narrowing 
of  the  palpebral  fissure,  or  the  holding  up  the  drooping  lid,  by  one 
of  the  forms  of  tarsorrhaphy,  or  combinations  of  these.  The  fact 
that  the  lid  in  this  variety  of  ectropion  does  not  so  much  incline  to 
inversion  of  the  tarsus  as  to  a  festooning  or  sagging  downward  of 
the  free  border,  constitutes  one  of  its  most  distinctive  features. 
In  other  words,  in  cases  of  long-standing  senile  ectropion,  the 
lower  lid  becomes  so  elongated  that  it  is  impossible  for  it  to  coapt 
nicely  with  the  globe,  even  if  the  original  cause  of  the  ectropion  were 
no    longer    active.     This    peculiarity    was    noticed    by    physicians 


Fig.  166. — Adam' 


atiun  fc 


in  the  early  days  of  modern  medicine  and  the  first  operations  con- 
ceived for  righting  the  defect  were  directed  to  this  fullness. 

Such  was  that  of  Sir  William  Adams ^  which  is  the  forerunner  of 
all  those  that  include  excision  of  the  tarsus.  This  surgeon  was  bold 
enough  to  excise  a  gore  from  the  very  center  of  the  lid  (its  size 
regulated  by  the  amount  of  surplus  in  the  lid)  that  included  the 
whole  thickness.  To  hold  the  edges  of  the  notch  in  apposition,  he 
put  in,  as  near  as  practicable  to  the  border,  a  surgical  pin,  on  to 
which  was  wound  a  figure-of-8  ligature.  For  the  rest,  fine  inter- 
rupted sutures  (Fig.  166). 

Von  Ammon,2  not  satisfied  with  the  cleft  often,  and  the  conspicu- 
ous scar  always,  left  in  the  middle  of  the  lid,  took  the  gore  from 
the  outer  canthus  (Von  Ammon-Adams  operation)  (Fig.  167),  then 
])roceeded  as  did  Adams;  yet  not,  as  has  been  slated  in  some  texl- 

1  Practical  Obs.  on  Ectrop.,  181 2,  p.  4. 

2  Zfits.  f.  Aut(.,  i,  R.  529. 


KUHNT-MUELLER 


287 


Fig.  167. 


Von  Anion's  modification  of  Adam's 
operation  for  ectropion. 


books,  as  did  Wallhcr, '  who  included  the  oulcr  e.xlremilics  oi  both 
lids  for  the  correction  of  double,  i.e.,  upper  and  lower,  ectropion 
(Fig.  168).  It  has  been  urged  against  these  operations,  when  made 
at  the  outer  canthus,  that  the  site  is  situated  too  far  from  the  point 
most  desirable  to  effect,  viz.,  the  vicinity  of  the  punclum.  Certainly, 
those  made  in  the  center 
have   as  many  faults. 

Of  later  years,  Kuhnt-  has 
given  still  another  moditica- 
tion  of  the  original  Adams 
operation.  The  accompany- 
ing illustrations,  taken  from 
Terrien's  excellent  work  on 
eye  surgery,  will  describe 
the  method  better  than 
words  (Figs.  169  and  170). 
It  will  be  seen  that  the  skin 
is  not  included  with  the  tri- 
angle cut  from  the  tarsus  and  conjunctiva.  While  there  is  no 
doubt  of  the  ability  of  the  operation,  in  many  instances,  to  relieve 
the  ectropion,  there  is  the  risk  of  the  cutting  through  of  the 
marginal  sutures,  and  the  leaving  of  a  permanent  nick.  Then,  too, 
the  decided  folding  of  the  skin  at  the  border  is  objectionable. 

L.    Miiller^  sought    to    remedy    these  shortcomings — and    not 
without    a    degree    of    success — by    altering    Kuhnt's    method,    as 

per     the     illustrations    (Figs. 

171  and  172),  also  taken  from 

Terrien.      The    sutures    that 

close   the  widest  part  of  the 

tarsal  V  are  held  on  one  side 

by  skin,  and  the  slack  of  the 

latter,  instead  of  being  taken 

up   in   one   pleat,    is   divided 

among  several. 

Helmbold,^     in     order     to 

obviate  the  tuck  of  skin  made  at  the  center  of  the  lid  in  the  Kuhnt 

operation,  removes  a  triangle  of  skin  corresponding  to  that  of  the 


Walther. 


1  Sj^st.  der  Chir.,  vi,  1S28. 

-  Beitrage  z.  operativ.  Augenh.,  i»»3,  J« 

3  Kl.  Mbl.  f.  Aug.,  Bd.  xxxi,  1893,  S.  11 

4  Klin.  Mbl.  iSg-j,  p.  283. 


Jena. 
3- 


ECTROPION 


tarsus,  but  further  out,  splitting  the  Hd  between  them      The  two  clefts 

thus  made  are  sutured  separately.     These  procedures  are  equally 

applicable  to  certain  cases  of  cicatricial  ectropion  as,  for  example, 

from  a  small  scar  that  may 
be  included  in  the  excised 
portion. 

A  quite  satisfactory  way, 
hit  upon  by  the  writer,  of  deal- 
m  ing  with  the  defect  in  ques- 
tion, is  to  make  canthotomy 
and  extend  slightly  the  skin 
cut,  then  loosen  around,  be- 
low, remove  a  small  triangle 
of  skin  containing  a  few  cilia, 
force  out — skin  as  it  were — ■ 
the  outer  extremity  of  the 
lower  tarsus,  grasp  it  with 
fixation    forceps,    and    while 

skin  and  conjunctiva  are  retracted,  pass  a  No.   2   silkworm,  or 

catgut,  suture  through,  from  without,  at  a  distance  from  the  cut 

end  proportioned  to  the  length  of  the  proposed  shortening,  after 

which  the  superfluous  bit  of 

the  tarsus  is  abscised.      Now, 

a  small  triangle  of  integument 

and  muscle   (base  in)  is  cut 

from    the    upper    lip  of    the 

canthotomy,  exposing  the  ex- 

ternal   canthal    ligament. 

Through  the  latter  is  passed, 

from  within,   the  suture  just 

put  into  the  tarsus,  the  ends 

are  knotted  and  cut  off  short, 

wliile    the    skin    o])ening    is 

united     by     line     black    silk 

■^    ,     ,  .  .      ,  Fig.  170.  — Kuhnl,  No.  J. 

sutures,  and  the  conjunctival 

incision  is  left  to  itself.     The  buried  suture  is  afterward  absorbed 

or  encapsuled  (Fig.  173). 

The  second  category  of  operations  for  atonic  ectropion  have  for 
their  object  the  pushing,  or  pulling,  the  lid  into  place  by  the  excis- 


KUHNT-MUELLER 


289 


ion  of  a  triangle  of  skin  and  muscle  near  the  outer  canthus,  the 
mobilizing  the  surrounding  edges,  and  the  closure  of  the  gap. 


I, 


Fig. 


-Miiller,  Xo.  i. 


The  first  of  these  was  that  of  DiefTenbach.^  This  consisted  in 
making  a  horizontal,  cutaneous  incision,  beginning  at  the  outer 
commissure,  whose  length  was  governed  by  the  amount  of  lid  slack 


to  be  taken  up.     From  the  extremities  of  this  incision  two  others  were 
made,  in  a  downward  direction,  so  converging  as  to  unite  in  forming 

1  Zeis  Handbook  f.  pi.  Chir.,  1838. 
19 


290 


ECTROPION 


Beard's  operation  for  elongated  lower  lid. 


an  equilateral  triangle.  The  skin  and  muscle  thus  enclosed  were 
extirpated.  The  outer  edge  of  the  lower  lid  was  pared  off  for  a 
distance  coinciding  with  the  length  of  one  side  of  the  triangle.     The 

skin  at  the  inner  side  of 
the  angle  and  beneath 
the  outer  half  of  the  lid 
was  undermined,  the 
whole  lower  lid  slid  out- 
ward, closing  the  angular 
opening,  and  the  coapt- 
ing  edges  were  sutured. 
Thus  the  pared,  or  raw, 
part  of  the  lid  margin 
becomes  the  lower  lip 
of  the  primary,  or  hori- 
zontal,    incision     (Figs. 

174,  175)- 
Method  of  Szyma- 
nowski.i — With  a  view  to  the  elimination  of  the  downward 
traction  of  the  scar  on  the  outer  commissure  and  also  to  the 
enhancement  of  the  effect,  this  surgeon  has  changed  the  form 
and  axis  of  the  Dieffenbach  triangle  (Fig.  176).  That  is,  he 
places  its  apex  at  the  commissure,  extends  one  short  side  up  and 
out,  gives  it  a  long,  vertical  base;  then  a  third  side,  of  intermediate 
length,  leading  back  to  the  canthus.  In  other  respects  the  method 
does    not    differ    from    Dieffen- 

bach's.     Thus,  the  upward  slant  ^^,,^:^^  ^ ''>^^;^^^\; 

of  the  short  side  gives  the  pro- 
cedure added  capacity  for  lifting 
up  the  lid,  and  the  long,  narrow 
cicatrix,  extending  as  it  does 
both  up  and  down  from  the  level 
of  the  commissure,  does  not  tend  x..  v    ,     ,   x- 

Fig.  174. — Dietfcnbach,  No.  i. 

to  the  latter's  displacement.  The 

effect,  moreover,  is  easier  to  dose  than  is  that  of  the  older  operation. 

The  outer  portion  of  the  lid  border  kT>  is  prepared  by  removing 
its  edge  to  a  depth  sufficient  to  include  the  hair  follicles,  and  for  a 
distance  commensurate  with  the  surplus  length  of  the  margin.  The 
incision  AB,  made  about  at  right  angles  to  the  tangent  of  the  curve 

1  Graefe-Saemisch  Ilandb.,  Bd.  iii,  S.  466. 


MF/niOD    OK    TKRSON 


!9I 


=^^^^^?^ 


Fic.  175. — Dierfcnl)ach,  No.  2. 


of  the  upper  border,  sliould  be  somewhat  lon,L,'er  than  AD.  UC  is 
nearly  three  times  and  C\  twice  as  long  as  AB.  In  undermining, 
to  mobiHzc  the  skin  and  mus- 
cle, only  the  side  AC  is  loosened,  ^^ 

and  to  the  extent  indicated  by      j^  if 

the  dotted  line,  leaving  the 
other  two  fixed  for  supports. 
In  closing,  the  opening  D  is 
sutured  to  B.  A  strong  point 
in  this  sort  of  operation  is  that 
the  elongation  of  the  tarsus  is 
definitely  disposed  of. 

The  third  class  of  operations  for  this  kind  of  ectropion  is  composed 
of  the  several  operations  for  tarsorrhaphy— or  blepharorrhaphy— 
already  described  (pp.  221-225)  for  occlusiofi  qf  some  portion 
of  the  palpebral  fissure.  It  may  be  the  external  tarsorrhaphy  of 
Fuchs,   the  internal   (German  median)   of  v.  Arlt,  or  the  median 

of  Panas.  He  would  rather 
trust  to  one  of  the  other  pro- 
cedures mentioned  in  connec- 
tion with  this  subject  or,  in  ex- 
treme cases,  to  a  combination  of 
more  than  one  of  them.  For 
example,  a  resection  at  the  outer 
commissure  in  conjunction  with 
a  Snellen  suture,  where  the  ectro- 
pion is  a  mixture  of  the  atonic 
and  the  mucous  types  or,  if  the 
operation  made  at  the  canthus 
failed  to  reinstate  the  punctum, 
one  could  resort  later  to  such 
a  procedure  as  that  of  Wharton- Jones  (Figs.  184-185) — placing  the 
apex  of  the  V  directly  beneath  the  punctum,  so  that  the  maximum 
of  pushing  upward  of  the  lid  would  be  where  it  would  do  the  most 
good.  In  the  event  of  an  incurable  paralysis  of  the  orbicularis, 
with  ectropion,  the  most  satisfactory  single  operation,  taken  all  in 
all,  is  probably  the  median  tarsorrhaphy.  It  will  more  surely  re- 
lieve the  troubles  from  epiphora  and  from  exposure  of  the  globe 
and  prove  more  lasting  as  to  its  benefits. 

Method    of    A.   Terson. — ^This    is  a   simplification   of    that  of 


Fig.  176. — Szynianowski 


292 


ECTROPION 


Szymanowski.  A  strip  of  the  thickened  conjunctiva,  extending  the 
entire  length  of  the  lower  lid,  is  dissected  out  (Fig.  177).  The  upper 
incision  by  which  the  strip  is  outlined  is  slightly  below  the  level  of  the 
canaliculus,  and  the  lower  somewhat  above  the  bottom  of  the  fornix. 
The  tarsus  is  spared.  A  triangle  composed  of  skin  and  orbicularis, 
with  its  base  toward,  and  just  outside  of  the  external  canthus,  is  also 
dissected  out.  The  skin  and  muscle  in  the  direction  of  the  eye  is 
undermined,  and  the  triangle  closed  as  shown  in  the  illustration, 
Fig.  178.  The  conjunctival  opening  is  left  to  close  spontaneously. 
"Strap"  Operation  of  Argyll-Robertson.— This  is  a  cleverly 


Fig.  177. — Method  of  A.  Terson. 


designed  method,  peculiarly  adapted  to  ectropion  wherein  the  ever- 
sion  is  chiefly  confined  to  the  outer  half  of  the  lower  lid.  Near  the 
outer  canthus  is  excised  a  wedge-shaped  piece  of  tissue,  including  the 
entire  thickness  of  the  lid.  This  disposes  of  the  excess  in  the  length 
of  the  free  border.  To  bring  the  cut  edges  of  the  resulting  notch  into 
approximation,  and  to  hold  up  the  lid,  a  strap  of  skin  is  fashioned 
as  shown  in  the  illustration  (Fig.  179).  The  extent  to  which  the  lid 
must  be  drawn  up  can  be  accurately  dosed  by  simply  pulling  the 
strap  upward  and  outward  along  its  groove.  The  overlapping  end 
of  the  strap  is  then  cut  off  and  the  remainder  of  it  is  fixed  by  suturing 
(Fig.  180). 

Operations  for  Cicatricial  Ectropion  and  Other  Blepharo- 
plasty. — It  is  customary  to  make  two  subjects  of  the  above  terms 


BLEPIIAROPLASTY 


'■93 


and  to  treat  ihcm  separately.  Technically,  one  means  a  turnin.t,' 
out  of  the  lid  from  a  cicatrix  and  the  other,  plastic  surgery,  for  the 
restoration  of  the  lid.  Seeing  that  some  part  is  destroyed  in  almost 
all  cases  of  the  ectropion  under  discussion  and  must  be  restored,  it  is 
a  pretty  difficult  matter  to  disunite  the  two,  even  in  theory,  and  as 
to  actual  practice,  they  are  one.  In  all  that  has  been  written  on 
"  blepharoplasty "  a  vast  majority  of  the  cases  cited  have  been 
those  of  cicatricial  ectropion.  An  operation  for  the  restoration  of 
any  part  of  the  nose  is  rhinoplasty;  for  any  part  of  the  lip,  chilo plasty— 
why  go  on  trying  to  perpetuate  "a  distinction  without  a  difference?" 


Fig.  17S. — Method  of  A.  Terson. 


This  is  the  most  common,  as  well  as  the  most  serious  form  ot 
ectropion  and  the  most  difficult  to  handle.  A  glance  at  the  more 
frequent  causes  of  partial  or  complete  destruction  of  the  eyelids 
and  the  kinds  of  cicatrices  they  leave  may  not  be  amiss.  First  in 
the  list  stand  burns  from  fire  or  chemicals.  These  are  apt  to  be 
deeper,  in  the  first  instance,  seeing  that  the  victim  often  receives  the 
injury  as  a  helpless  babe,  or  invalid  (epileptic),  and  the  contact  is 
prolonged;  while,  in  the  second  (those  from  strong  caustics  and 
acids)  they  usually  affect  the  skin  only.  Next  in  point  of  frequency 
is  epithelioma,  or  rodent  ulcer,  which,  when  situated  in  the  region  of 
the  tarsus,  usually  destroys  the  whole  thickness  of  the  lid  within  the 
ulcerated  area.     The  scars  from  syphilis  and  lupus,  like  those  from 


294 


ECTROPION 


lire,  althou<^li  the  disease  is  primarily  from  the  skin,  are  liable  to 
penetrate  beyond  it.  Another  cause  of  cicatricial  ectropion  that 
has  come  well  to  the  front,  particularly  in  the  vicinity  of  Chicago, 
is  blastomycosis  or  blastomycetic  dermatitis.  The  resulting  scar 
rarely  reaches  below  the  superficial  fascia. 

The  gra\-est  cases  will  sometimes  tax  the  resources  and  per- 
severence  of  the  surgeon  to  the  utmost  and,  unfortunately,  exhaust 
those  of  the  patient  completely.  As  before  hinted,  the  nature  of 
the  primary  injury  and  its  extent  considered  together  with  its 
date,  will  govern  in  the  choice  and  compass  of  the  surgical  measure 


Fig.  179. — ^\rgyll-Robertson's  strap  operation — incisions 


selected  for  the  relief  of  the  ectropion.  Now  and  then  one  meets 
with  an  eversion  of  the  lid  from  a  scar  so  slight  that  the  mere 
subcutaneous  division  of  a  restraining  band  or  the  excision  of  the 
entire  cicatricial  mass,  followed  by  the  mol)ilization  and  righting 
of  the  tarsus  and  closure  of  the  ojjcning,  with  perhaps  conscc[uent 
massage  and  stretching  of  the  affected  skin,  will  lead  to  perfect 
cure.  As  a  rule,  howe\-er,  the  indispensable  element  i)i  the  surgical 
management  of  cicatricial  ectropion  as  ivell  as  in  blepharoplasiy,  in 
general,  is  ihr  replacing  of  lost  substance,  whicli  refers  mainly  lo  the 
skin. 


STRAP    OPERATION 


295 


There  arc  four  ways  of  oljtainin.L;  llie  borrowed  integument 
and  of  bringing  it  to  its  new  situation  to  fill  the  defect : 

1.  By  fashioning  and  mobilizing  flaps  of  the  adjoining  skin 
and  putting  them  in  place  by  simple  sliding  or  interchanging. 
Autoplasly  by  the  French  method. 

2.  By  cutting  pedunculated  Haps  from  the  nearby  skin,  not 
necessarily  adjacent  to  the  defect,  and  moving  them  into  position 
by  turning  or  twisting  of  tlieir  pedicles.  Autoplasly  by  the  Indian 
method. 

3.  By  entirely  detaching  pieces  of  skin  of  various  dimensions 
from  a  distant  locality  and  transplanting  them  in  or  about  the  lid. 
Autoplasly  {or  heleroplasty)  by  cutaneous  grafts. 


Fig.  180. — Argyll-Robertson's  strap  operation — result. 


4.  By  transporting  a  pedunculated  flap,  formed  from  a  remote 
part  of  the  patient's  body  or  from  the  body  of  another  individual. 
Autoplasly  {or  heleroplasty)  by  the  Italian  method. 

The  first  two  refer,  of  necessity,  to  autoplasty  pure  and  simple, 
and  to  that  only.  That  is,  the  integument  is  taken  from  the  same 
individual,  and  from  the  immediate  vicinity,  or  from  one  but 
slightly  removed.  The  third  mode,  w^hile  usually  autoplastic,  is 
occasionally  heteroplastic,  in  that  the  material  is  taken  from  another 
person,  or  it  has,  in  rare  instances,  been  zooplastic — got  froin 
skin  belonging  to  one  of  the  lower  animals.     The  fourth,  although 


296  ECTROPION 

not  of  necessity  autoplastic,  has,  as  far  as  it  concerns  blepharoplasty, 
never  been  anything  else. 

It  were  vain  to  attempt  an  enumeration  of  the  various  operative 
schemes  of  more  or  less  merit  that  have  been  devised  for  cicatricial 
ectropion,  much  less  to  think  of  describing  them.  Let  it  suffice, 
therefore,  to  detail  a  few  representative  procedures,  under  the 
several  headings,  and  to  present  certain  other  examples  by  means  of 
pictures  that  will  speak  for  themselves. 

I.  The  first  (French)  mode  is  best  adapted  to  cases  in  which  the 
loss  of  lid  tissue  and  that  of  the  surrounding  skin  has  been  relatively 
small.  This  is  not  to  say  that  the  method  is  applicable  only  to 
partial  or  circumscribed  ectropion.  On  the  contrary,  the  latter 
may  be  complete,  and  affect  either  one  or  both  lids.  And  part 
of  the  available  integument  may  be  cicatricial,  yet  it  must  be  not 
deeply  scared  over  any  considerable 
area,  and  must  be  capable  of  being 
loosened  from  beneath,  and  made  into 
sliding  flaps,  excepting  for  such  limited 
portions  as  will  admit  of  being  excised 
without  being  detrimental  to  the  gen- 
eral result.  Tarsorrhaphy,  provisional 
or  definitive,  was  a  necessary  adjunct 
'^ .  '         to  most  of  these  operations,  but  it  may 

^"""'  often   be   omitted,  and   the   ultimate 

Fig.  i8r. — -Yon  Ammon.  .,  ,     .    ,  .    ,  ,  .  , 

eftect  heightened  by  overlappmg  the 
lids,  and  fixing  the  operated  one  by  collodion  or  other  means. 

Given  an  ectropion  from  a  deep  circumscribed  cicatrix  with  its 
long  axis  vertical,  and  that  cannot  be  readily  excised,  as  wdien  con- 
tinuous with  bone,  one  may  have  recourse  to  the  process  of  Van 
Ammon  (Fig.  181).  This  consists  in  surrounding  the  cicatrix 
by  an  elliptical  incision,  removing  its  top  to  a  depth  corresponding 
with  that  of  the  contiguous  skin,  and  leaving  the  rest  to  be  buried. 
Free  dissection  is  made  all  about  the  opening,  the  lid  is  righted, 
pushed  up  high  onto  the  globe,  and  the  wound  closed  by  interrupted 
sutures. 

For  ectropion  of  the  lower  lid,  from  a  deep  scar  of  moderate  size, 
if  not  too  near  a  commissure,  the  old  operation  of  DiefTenbach 
is  still  practised.  The  adherent  portion  is  encompassed  by  three 
straight  incisions  that  form  a  triangle  with  its  base  near  and  parallel 
with  the  free  border.     The  area  thus  enclosed  is  excised.     From 


WHARTON-JONES 


297 


either  extremity  of  the  incision  formin<^'  the  base  of  the  trianj^le, 
start  a  short  incision,  each  about  one-half  the  len^^th  of  said  base, 
both  lightly  curving,  the  one  down  and  out,  the  other  down  and  in. 
The  upper  li])  of  llic  whole  incision  is  undermined  up  to  the  lid 
border,  and  the  lid  turned  back  into  position.  The  lateral  flaps  are 
dissected  up  and  brought  together,  the  resulting  lines  of  union  present- 
ing the  shape  of  a  capital  T.  External  tarsorrhaphy  completes 
the  operation  (Figs.  182  and  183).  It  is  rather  curious  to  note  that 
von  Graefe,  according  to  Baudry,^  applied  the  same  operation, 
minus  the  tarsorrhaphy,  to  entropion  of  the  lower  lid. 


Fig.  182.— Dieffenbach. 


Fig.  18;. — Dieffenbach. 


A  classic  operation  for  cicatricial  ectropion  of  either  upper  or 
lower  lid,  is  that  of  Wharton- Jones,  slightly  modified  by  Sanson 
(Figs.  184  and  185).  Two  converging  incisions,  beginning  near  the 
free  border,  are  made  to  include  the  scar  and  meet  beyond  it,  like 
the  letter  V,  upright  for  the  lower  lid,  inverted  for  the  upper.  The 
triangular  flap  is  loosened  from  its  apex  to  its  base  at  the  cilia,  and 
the  surrounding  skin  is  undermined.  The  lid  is  righted  and  the 
approximating  lips  of  the  incision  are  joined  by  sutures,  the  lines 
of  juncture  now  resembling  a  Y  instead  of  a  V.  Tarsorrhaphy  may 
be  added,  or  the  lid  may  be  anchored  by  collodionized  strips  of 
gauze  to  the  cheek  (if  the  upper)  or  to  the  forehead  (if  the  lower). 
Such  an  operation  has  a  great  advantage  over  those  like  that  of 
Dieffenbach  in  that  it  does  not  call  for  a  further  sacrifice  of  integu- 
ment, and  should  have  precedence  whenever  practicable. 

Von  Graefe  conceived  the  idea  of  correcting  extensive  ectropion 
of  the  low^er  lid  by  making  a  flap  the  whole  width  of  the  lid  and 
extending  downward  ten  to  twelve  millimeters.  He  split  the  lid  into 
its  two  leaves,   the   anterior  composed   of  skin   and   muscle,   the 

^  Technique  Operatoire,  Paris,  1902,  p.  700. 


298 


ECTROPION 


posterior  of  tarsus  and  conjunctiva,  by  an  intermarginal  incision 
the  entire  length  of  the  palj)cbral  lissure.  From  the  ends  of  this 
ran  two  vertical  cuts,  extending  as  far  as  the  lower  rim  of  the 
orbit.  The  flap  thus  outlined,  was  dissected  up,  the  ectropion 
corrected  and  the  tarsus,  together  with  the  overlying  flap,  forcibly 

drawn  upward.     The  flap  was 


then  joined  to  the  adjacent 
skin  by  interrupted  sutures, 
beginning  below,  for  about 
one-half  the  distance.  The 
top  or  elongated  corners  of 
the  flap  were  rabbeted  (Fig. 
186  a  he).  The  upper  edge, 
thus  shortened,  was  put  upon 
the  stretch  and  stitched  to  the 
free  border  of  the  tarsus,  the 
ends  of  thread  being  left  long 
and  fastened,  in  a  pad  of 
collodionized  cotton,  to  the 
were  placed  in  the  remaining 
a  compressive  bandage.     The 


Fig. 


54. — Wharton- Jones,  No   i. 

forehead.     A  few  shallow  sutures 

vertical  skin  openings  and  over  al 

chief  objection  to  this  operation  lies  in  the  fact  that  new  tissue  is 

not  supplied  to  help  the  graft  in  supporting  the  lid. 

F.  Jaeger  1  devised  a  thoroughly  rational  and  practical  operation 
for  cicatricial  ectropion  of  the  upper  lid,  where  the  ciliary  border 
was  so  displaced  as  to  lie  close 
to  the  supercilia.  It  may  be 
classed  as  a  sliding-flap 
method.  He  made  cutaneous 
incision  as  long  as  the  palpe- 
bral fissure,  close  to  and 
parallel  with  the  margin,  un- 
dermined the  tarsus  and 
turned  the  lid  down  into  ])lace. 
If  the  border  seemed  much 
elongated,  he  excised  from  the 
center  a  wedge  that  included 
the  entire  thickness  and  brought 
by   means  of    a  surgical    ])in  and 


/x:^}^ 


■ir,.   1S5.      Wharton-Joncs,  No.  2. 

ogclhcr  the  edges  of  the  notch 
'igurc-()f-8   ligature.     Figs.    187 


Jaeger-Dryer, Novo  blephar.  inelliodus,  1S31,  p.  28. 


GRAEFE  S    METHOD 


299 


and  188).  The  u])i)t'r  edge  of  ihc  ojjcn  ellipse  was  dissecled  for 
a  considerable  distance,  that  is,  the  skin  of  the  entire  brow 
as  far  as  the  middle  of  the  forehead  and  out  to  the  temjjle  was 
loosened,  and  the  whole  drawn  down  to  cover  the  openin,^,  and  the 
wound  closed  by  sutures. 

In  the  light  of  modern  methods,  the  triangular  excision  of  the 
free  border  alluded  to  in  this  oijcration  would  be  made  at  the  outer 


Fig.  186.— a,  b  and  c,  Graefe's  operation  for  cica 


canthus,  a  la  \^on  Ammon- Adams,  or  after  the  Kuhni-:\luller  mode 
(only  in  upper  lid).  The  lid  would  be  drawn  away  down,  overlap- 
ping its  fellow,  and  f^xed  to  the  cheek  by  collodion,  and  the  large  raw 
opening  would  be  covered  either  by  a  i)ediceled  flap  or  by  a  graft. 
One  of  the  earliest  and  best  examples  of  a  sliding-flap  operation 
for  blepharoplasty  is  that  devised  by  Dieffenbach,i  ^yhjig  professor 
of  surgery  in  Berlin,  about  1835.     The  process  could  be  applied 

1  Casper's  Woch.,  Bd.  i,  S.  8. 


300 


ECTROPION 


to  restoration  of  the  outer  leaf  or  of  the  whole  thickness  of  the 
lower  lid,  and  was  as  follows:  by  removal  of  the  offending  tissue, 
a  triangular  opening,  with  base  upward,  was  made  below  the  eye 


Fig.  187. — Jaeger's  operation  for  ectro- 
pion of  the  upper  lid.  Dotted  line  is  line 
of  incison. 


Fig,  188, — Same  lid  turned  down. 


(Fig.  189),  ahc,  taking  care  to  conserve  the  conjunctiva.  From 
the  outer  canthus,  extending  horizontally  outward  for  a  distance 
equal  to  the  length  of  the  palpebral  fissure  (or  to  the  base  of  the 
triangle) ,  another  incision,  hd,  and  from  the  extremity  of  this  one,  down 
and  in,  and  parallel  with  the  outer  side  of  the  triangle,  still  another, 
de.     The  trapezoid  flap  thus  marked  out,  was  loosened  from  summit 


Fig.  1S9.  Fig.  190. 

Figs.  189  and  190. — Dieffenbach's  blepharoj)Iasty,  e.g.,  in  the  removal  of  a  growth. 


to  base,  slid  over,  bringing  b  to  a,  then  sutured  internally  to  the  skin 
and  superiorly  to  the  conjunctiva.  The  secondary  bared  space, 
bde,  was  left  to  heal  by  granulation  (Fig.  190).  To-day  this  space 
would  be  covered  by  a  graft.  Indeed,  Angelucci  and  many  others 
have  so  treated    this  space.     Angelucci  broadened  the  top  of  the 


SZYMANOWSKY 


301 


flap  as  shown  by  ihc  doUcd   lines,  and  employed  a  pedunculated 
flap  from  the  temple  for  the  secondary  defect. 

Szymanowsky,!  with  the  view  to  a  closer  approximation  of  the 
secondary  defect,  and  in  order  to 
obtain  more  tissue  for  replacing 
loss  in  the  lower  lid,  extended  the 
incisions  according  to  the  dotted 
lines  (Fig.  189).  P^or  the  restora- 
tion of  the  inner  lialf  of  the  lower 
lid,  Arlt  modified  the  operation  as 
shown  in  Fig.  191.  To  avoid  the 
outward  stretching  of  the  new  lid 
and  the  displacement  of  the  external 
commissure  that  would  result  from 
the  Dieffenbach  procedure,  Harlan, - 
of  Philadelphia,  made  the  rather  elaborate  operation  pictured  in 
Fig.  192.  The  broad  space  beneath  the  eye  was  narrowed  as 
much  as  practicable  by  undermining  and  bringing  the  lower  edges 
together  before  sliding  the  flap  into  place,  and  the  same  was  done 
with  the  second  triangle  on  the  temple.  Thus,  not  only  was  the 
secondary  defect  reduced  in  size,  but  so  elevated  as,  by  its  healing, 


Fig.  191 


Fig.  192. — Harlan. 

not  to  exert  an  evil  influence  on  the  position  of  the  lids.     Another 

advantage  claimed  was  that,  being  stitched  on  either  side  to  sound 

skin,  the  nutrition  of  the  new  lid  was  better  assured  than  if,  on  one 

side,   it  were  left  to  form  the  margin  of  an  extensive  granulating 

surface.     Harlan's  operation  was  for  an  epithelioma  involving  the 

entire  lower  lid.      Three   years   afterward,   "the  canthus  was  in 

normal  position  and  the  deformity  was  slight." 

^  Graefe-Saemisch,  iii,  S.  476. 

^  Norris  and  Oliver,  p.  11  7-1 18,  1S9S. 


302 


ECTROPION 


A  pure  specimen  of  the  sliding-flap  operation  is  that  devised 
by  Knapp,^  and  made  for  the  repair  of  a  lower  lid  whose  inner 
two-thirds  were  sacrificed  in  the  removal  of  a  chancroid.  Flaps 
were  constructed  as  per  the  lines  in  Fig.  193.  After  excision  of  the 
section  containing  the  ulcer,  the  two  flaps,  having  been  dissected 
loose  from  free  end  to  base,  were  butted  together  and  sutured. 
The  result  was  excellent. 


Fig.  193. — Knapp. 

As  a  good  illustration  of  a  totally  wrong  principle  in  a  sliding-flap 
operation,  I  would  cite  the  method  of  Burow.^  Here  the  triangle 
of  skin,  aed  (Fig.  194),  is  excised  and  thrown  away,  in  order  that,  in 
the  mobilized  integument,  d  may  slide  to  a  and  a  to  6  and  close  the 
openings.  There  is  no  chance  of  supplying  suitable  borrowed 
tissue  for  the  secondary  defect.  In  other  words,  the  loss  of  tissue 
contiguous  to  the  eye  is  exactly  doubled.     Much  more  rational  is 


Fig.  194. — Burow. 

the  Dieffenbach  operation,  wherein  the  resulting  raw  surface  may 

be  covered  by  a  pedunculated  flap,  cut  from  skin  more  remote 

from  the  lids,  or  by  a  cutaneous  graft. 

Method  of  Blepharoplasty  for  Central  Colobomaof  the  Upper 

Lid. — (By   Professor   F'ranccsco    Falchi,    of    Pavia,    Italy.)^     The 

1  Archiv.  f.  Oph.  xiii,  1,  S.  183. 

*  Berlin,  1856. 

^  Archiv.f.  Augent.,  LIX  Band,  Heft  3,  1908 


FALCHI S    METHOD 


303 


coloboma  may  be  con.s^cnital  or  a((|iiirc(l,  the  procedure  is  applicable 
to  either.  It  has  been  demonstrated  to  be  thorou.^hly  practicable 
and  successful. 


Fig.  195. — Falchi's  method  of  biepharoplasty  for  central  coloboma  of  the  upper 


Fig.  196. — Falchi's  method  of  biepharoplasty  for  central  coloboma  of  the  upper  lid. 

First  Step.- — Freshening  raw  the  whole  free  border  or  the  inter- 
marginal  spaces,  of  the  affected  eye.  >,i  j 
Second  Step. — ^Freshening   the   raw   edges  of  the  coloboma  and 


304 


ECTROPION 


forming  it  into  a  sharp  angle.  This  is  best  done  with  a  convex 
scalpel,  cutting  upon  the  Jaeger  horn  plate  as  a  base.  It  can  also 
be  accompHshed  with  small,  straight  scissors  (Fig,  195). 

Third  Step. — ^A  perpendicular  incision  upward  from  the  outer 
commissure,  the  entire  width  and  thickness  of  the  lid,  the  conjunctiva 
included  (Fig.  195). 

Fourth  Step. — ^Closing  the  notch  in  the  upper  lid  by  sutures,  and 
tarsorrhaphy  of  the  inner  two-thirds  of  the  upper  lid  with  the  corre- 
sponding portion  of  the  lower  (Fig.  196). 

Fifth  Step. — ^Skin  incision  outward  and  slightly  downward,  from 
the  external  canthus,  somewhat  greater  in  extent  than  the  outer  third 


Fig. 


-Falchi's  mehod  of  blepharoplasty  for  central  coloboma  of  the  upper  lid. 


of  the  lower  lid  margin.  From  the  outer  extremity  of  this  another 
incision  upward,  parallel  with  the  one  made  vertical  to  the  commis- 
sure, and  extending  to  the  tail  of  the  eyebrow.  The  flap  thus  out- 
lined is  dissected  up,  slid  over,  and  stitched  both  to  the  adjoining 
flap  and  to  the  outer  third  of  the  lower  lid  margin.  At  the  temporal 
side  there  now  remains  a  triangular  defect  into  which  is  fitted  a 
Wolfe  graft  from  the  inner  side  of  the  upper  arm,  according  to  the 
principles  laid  down  under  "Dermic  drafts"  (Fig.  197). 

In  order  to  obtain  the  iK'st  results  both  eyes  are  kept  bandaged 
for  one  month.  The  eye  is  re-dressed  at  the  end  of  forty-eight 
hours,  and  daily  after  that.  The  sutures  are  removed  in  fourteen 
to  sixteen  days,  but  the  adhesion  between  the  lid  borders  is  not 


INDIAN    METHOD  305 

severed  until  six    weeks    to    two    months    have    elapsed    since    the 
operation. 

2.  The  Indian  Method. — In  the  ancient  days  of  India  there  was 
endless  strife  between  the  black  races,  with  their  ugly  flat  noses,  and 
the  lighter  Aryan  invaders,  with  their  boasted  nasal  prominence  and 
beauty.  Hence,  the  nasal  feature  soon  became  the  target,  not  only 
for  ridicule  and  scorn,  but  for  actual  violence — legal  and  otherwise. 
Hence  also  the  Hindu  surgeons  were  early  in  devising  means  for 
the  restoration  of  the  mutilated  organ.  Among  their  methods  was 
that  of  building  up  the  lost  portions  of  the  nose  by  transplanting 
pedunculated  flaps  of  skin  from  the  adjoining  cheek.  When  the 
same  was  applied  to  the  plastic  surgery  of  the  lids,  it  was  referred  to 
as  the  Indian  method.  Blepharoplasty  was  not  practiced  to  any  ex- 
tent, however,  until  the  third  decade  of  the  nineteenth  century,  and 
almost  all  the  earlier  attempts  were  after  the  Indian  method — that  is, 


Fig.  198. — Fricke. 

by  rotation  of  pedunculated  flaps,  taken  from  the  nearby  skin,  with 
more  or  less  twisting  of  their  pedicles.  The  first  to  claim  having 
successfully  restored  a  lid  in  this  way  was  Carl  Ferdinand  Graefe.^ 
In  1818,  this  surgeon,  after  several  years  in  trials  of  various  means, 
reported  some  of  his  experiences.  Among  them  was  the  building 
up  of  the  lids  by  both  this  and  the  Italian  methods.  In  the  same 
article  (p.  19)  it  is  stated  that  Dzondi  had  essayed  the  renewal  of  the 
lower  lid  by  a  flap  taken  from  the  cheek,  but  had  failed. 

The  procedure  was  systematized  and  given  its  flrst  real  impetus 
by  Fricke,^     His  operations  related   mainly  to  the  correction  of  ci- 

1  Journal  of  v.  Gracfe  and  Wallher,  ii,  p.  18. 

2  Bildung   neuer   Augenlider   nach    Zerstorung    und    dadurch    hervorge- 
brachter  Auswiirtswendung  derselben.      Hamburg,  1829. 


3o6 


ECTROPION 


catricial  ectropion — ihe  tarsus,  conjunctiva,  and  free  border  having 
been  intact.  Fricke's  perfected  operation  \vas  as  follows:  given  a 
case  of  complete  cicatricial  ectropion  of  the  upper  lid,  for  example, 
an  incision  was  made  between  cilia  and  supercilia,  parallel  with  the 
rim  of  the  orbit,  the  tarsus  loosened  from  its  attachments,  and 


Fig.  199. — Blasius. 

turned  down  into  place,  thus  leaving  an  oval  raw  surface  (Fig.  198). 
A  flap,  somewhat  larger  than  the  oval,  was  cut  from  the  forehead 
and  temple,  whose  base,  broader  than  the  body  of  the  flap — not  a 
pedicle  in  the  strict  sense  of  the  word — was  situated  a  little  external 
to  the  margin  of  the  orbit  and  slightly  above  the  operated  lid. 
Before  turning  the  flap  into  its  new  position,  the  bridge  of  skin 


Fig.  200. — Blasius. 

between  the  two  raw  areas  was  excised  sufliciently  to  receive  the 
pedicle  or  base.  It  was  found  that  this  was  more  satisfactory  than 
to  allow  the  pedicle  to  lie  on  top  of  an  isthmus  of  skin,  with  the  view 
of  cutting  and  trimming  it  later.  The  flap  was  held  in  place  by 
numerous  sutures,  and  the  gap  from  whence  it  came,  or  the  sec- 
ondary defect,  was  left  to  heal  by  granulation. 


FRICKK    AM)    15I.AS1US 


307 


So  far  as  it  goes,  this  (>])crati()n  of  Frickc  is  cssfnlially  tlic  sanu- 
as  performed  by  his  successors  and  by  many  sur<,a'ons  for  the 
same  deformity  to-(hiy.  The  variations  have  been  mainly  as  to  the 
region   from  which    the    llaj)  was  laken^this  has  been  covered  but 


•^^M 


«X-,-}v. 


Fic.  20 


-Denonvilliers. 


in  what  manner  is  a  matter  that  has  been  governed  by  the  judgment 
of  the  operator  and  by  the  pecuharities  of  the  case. 

Blasius,^  for  the  restoration  of  the  entire  lower  lid  at  one  time,  took 
a  flap,  pedicle  inward,  from  the  side  of  the  nose  and  the  forehead. 
(Fig.  199.)     At   another  time,  for  replacing  the  lower  lid,  pedicle 


outward,  from  the  temple  and  forehead  (Fig.  200).  For  an  ex- 
treme ectropion  of  the  whole  lower  lid,  Denonvilliers  utilized  an 
enormous  flap,  cut  from  in  front  of  the  ear,  with  pedicle  just 
external  to  the  outer  canthus  (Figs.  201  and  202).  For  the  repa- 
ration of  an  angular  loss  of  sul^stance— external  or  internal-  -the 
1  Med.  Zeit,  Miirz.  1S42. 


3o8 


ECTROPION 


bifurcate  pedicle,  as  first  employed  by  Hasner,  serves  admirably 
(Figs.  203  and  204).  For  a  yet  more  elaborate  restitution  of  a 
commissure,  the  process  of  Richet^  is  cited.  The  primary  defect 
was  an  inferoexternal  ectropion,  from  an  adherent  scar  of  the 
orbital  rim,  with  fungus  growth. 

After  crescentic  excision  of  the  diseased  portion  a  and  righting 


Fig.  204. — Hasner. 

of  the  lid  (Fig.  205),  a  provisional  tarsorrhaphy  was  made  and 
the  threads  were  attached  to  the  brow  by  collodion.  Next,  the 
flaps  b  and  c  were  fashioned  (Fig.  206),  which  were  interchanged 
and  sutured  to  cover  the  defect  as  shown  in  Fig.  207. 


■-A 


-Richet. 


Fig.  206. — Richet. 


Some  years  ago,  I-  reported  the  restoration  of  the  entire  right 
lower  lid  and  the  outer  third  of  the  upper  by  a  mitten-shaped  flap 
formed  from  the  cheek.  The  breadth  of  the  mitten  was  so  great  at 
its  widest  portion  that  it  was  impossible  to  approximate  at  this 
point  the  edges  of  the  secondary  defect,  and  a  cutaneous  graft, 
taken  from  the  arm,  was  put  in  to  fill  the  space;  Fig.  208  shows 

1  Recueil  d'ophtalmologie,  1873. 

2  Am.  Jour,  of  Ophthalmology,  June,  1897. 


LANDOLT  S    METHOD  309 

the  result  three  years  after  the  o])eration.  The  case  was  that  of 
an  elderly  woman,  and  ihe  parts  had  been  destroyed  by  a  rodent 
ulcer. 

In  place  of  borrowing  skin  to  one  side  of  a  commissure,  above 
or  below,  as  in  the  examples  just  given,  the  llap  has  l)ecn  taken 
from  one  lid  to   replace  tissue  lacking  in 
the  other,     Landolt^  made  from  the  upper 
lid  a  bridge,  or  double  pcdiceled  llap,   to 
restore   the   lower    lid   that   had  been  de- 
stroyed by  a  carcinoma.     An  incision   was 
made  through  skin  and  muscle,  two  milli- 
meters  from  and  parallel  with  the  upper 
margin,  and  extending  at  either  end  some- 
what beyond  the  canthus.      This  was  re- 
peated   seven  or  eight  millimeters  higher         fig.  207.— Richter. 
up,  and  the  intervening  strip  of  skin  and 

muscle  was  loosened  throughout  its  length,  except  at  the  ends. 
The  conjunctiva  was  separated  from  the  lower  free  border,  from 
canthus  to  canthus,  sufficiently  to  receive  the  flap,  which  was 
transposed  to  fill  the  gap  and  there  stitched.  The  upper  lip  of 
the  superior  opening  was  undermined,  and  the  skin  drawn  down  and 
sutured  to  the  lower  lip.  At  the  proper  time  the  pedicles  were  cut 
and  trimmed  to  fit  (Fig.  209). 

Panas^  made  a  regular  practice  of  taking  from  one  hd  and  giving 
to  the  other,  though  through  a  single  pedicle  left  near  the  outer 
canthus,  and  he  usually  subjoined  provisional  tarsorrhaphy. 
This  robbing  of  Peter  to  pay  Paul  would  seem  hardly  justifiable 
if  suitable  tissue  for  the  flaps  could  be  found  outside  the  longitude 
of  the  palpebral  fissure,  for  the  reason  that  it  is  inadvisable  to 
have  the  hulk  of  the  secondary  defect  contiguous  to  the  lid  margins. 

This  brings  us  to  a  consideration  of  such  c^uestions  as  the  prepara- 
tion of  the  lid  and  the  selection  and  outlining  of  the  flap.  Besides 
the  principle  just  stated,  there  are  a  number  of  others  to  be  observed 
in  this  connection.  Before  proceeding  to  mark  out  the  skin  that 
is  to  be  transplanted,  its  new  site  is  opened  up  and  carefully  prepared, 
so  that  its  size  and  shape  may  be  apparent,  and  all  bleeding  may 
be  stopped  in  due  time.  If,  as  is  most  often  the  case,  the  operation 
is  for  the  correction   of   ectropion,    an    incision    is   made   through 

1  Archiv.  d'oi)ht,  1885,  p.  492. 

2  Clin,  opht.,  1899,  p.  31. 


3IO 


ECTROPION 


the  skin,  three  or  four  milHmeters  from  the  free  border,  whose 
length  somewhat  exceeds  that  of  the  everted  part.  The  lips  of 
this  immediately  retract,  and  the  opening  thus  formed  is  deepened 
till  muscle  or  underlying  fascia  is  reached.  The  free  border  is 
seized  by  fixation  forceps  and  pulled  toward  its  normal  ])Osition, 
the  dissection  being  meanwhile  carried  toward  the  convex  bor- 
der of  the  tarsus.  The  latter  and  the  orbicularis  are  spared; 
that  is,  the  restraining  cicatricial  bands  are  divided  without  cutting 


Fig.  2o8.^Beard.     Restoration  of  lower  lid  and  part  of  upper  by  mitten-shaped  flap. 


the  muscle  and  the  tarsus,  and  the  anchylosis  between  the  tarsus 
and  underlying  tissue  is  entirely  freed.  "The  removal  of  all  scar 
tissue,"  once  thought  im]jerati\e,  is  no  longer  so  rigidly  insisted  upon. 
The  harder  masses  are  best  gotten  rid  of,  pcrhai)s,  but  to  attempt 
the  excision  of  all  of  it  is  not  feasible. 

The  same  allowance  is  made  for  the  subsequent  contraction  of 
the  oval  bared  space  thus  created,  as  for  that  of  the  skin  that  is 
to  cover  it.  Hence,  this  preliminary  opening  up  is  made  extreme; 
to  such  a  degree,  for  example,  that  for  complete  ectroi)ion  of  the 
upper  lid  its  free  border  would  o\crlap  the  lower  lid  and  lie  upon 


LOCATING    THE    PEDICLE 


31: 


the  cheek,  opposite  the  inferior  portion  of  the  rim  of  the  orbit  or 
even  below  it.  The  more  recent  the  injury  that  caused  the  misplace- 
ment, the  greater  must  be  this  overcffecl.  U  the  ()|)craii()n  is  to 
restore  the  lid  after  removal  of  a  growth,  or  the  excision  of  an  ulcer 
that  involves  the  whole  thickness,  the  conservation  of  the  maximum 
amount  of  the  conjunctiva  is  important. 

For  the  entire  upper  (or  lower)  lid  or  any  |)art  external  to  the 
middle,  the  pedicle  is  best  situated  about  on  a  level  with,  and  close 
to,  the  outer  canthus,  and  the  long  axis  of  the  flap  should  be  directed 
upward    (or  downward).     Some  of    the  older   surgeons    have  ad- 


l'"iG.  2oq. — Landoll. 

vised  that  a  flap  to  replace  the  upper  lid  be  taken  from  the  malar 
region,  and  one  for  the  lower  from  the  temple,  for  the  reason  that  the 
strain  of  cicatrization  in  the  secondary  defect  will,  in  this  arrange- 
ment, tend  to  enhance  the  desired  effect.  As  regards  the  body  of 
the  second  bared  space,  however,  it  signifies  but  little,  yet,  as  con- 
cerns the  position  of  the  pedich\  il  docs  make  a  dilTerence.  On 
account  of  its  ])roximity  to  the  original  defect,  to  elevate  il  for  the 
lower  lid  and  to  depress  it  for  the  upper,  contributes  to  its  success. 
Moreover,  in  male  subjects,  it  is  difficult  to  fashion  a  flap  from  the 
cheek  without  including  the  hair  follicles  of  the  beard,  and  the 
presence  of  hairs  in  the  flap — no  matter  how  few  or  small  they  may 
be — is  objectionable.  Yet  we  have  seen  patients  exhibited  with  great 
gusto  who  had  been  furnished  with  a  new  set  of  eyelashes  borrowed 
from  the  supercilia.  For  circumscribed  defects  situated  more  to- 
ward the  nasal  side  of  the  lids,  the  glabellar  and  nasomaxillary  regions 
offer  the  more  lifting  skin  for  j)edunculated  flaps;  and  whether  or 
not  they  are  taken  from  the  former  for  the  lower  lid  and  from  the 
latter  for  the  upper,  as  advised  by  many  surgeons,  the  pedicle  at 
least  should  be  slightly  higher  than  the  canthus  when  the  lesion  is 


312  ECTROPION 

of  the  lower  lid,  and  vice  versa.  If  only  scar  tissue  is  available  for 
the  flap,  it  also  may  be  utilized,  provided  it  is  superficial,  movable, 
and  not  too  greatly  contracted. 

In  the  matter  of  choosing  a  flap,  it  is  often  not  so  much  a  question 
as  to  what  one  would  like  to  have,  as  what  one  can  get.  In  cutting 
the  subsidiary  integument,  if  it  lies  close  to  the  inner  canthus,  the 
lacrimal  canal  is  to  be  respected,  and  if  in  the  malar  or  infra- 
zygomatic  region,  the  duct  of  the  parotid  gland  is  to  be  avoided. 
As  has  been  intimated  already,  the  pedicle  should  be  situated  as 
near  as  practicable  to  the  primary  defect,  and  the  body  of  the  sec- 
ondary defect  more  remote.  If  a  desirable  skin  area  can  be  reached 
by  moderate  elongation  of  the  pedicle,  it  may  be  so  extended,  but 
a  roadway  or  bed  should  be  opened  through  the  intervening  bridge 
of  skin  where  to  inlay  this  long  neck,  rather  than  have  it  lie  on  top. 
It  is  hardly  proper  to  refer  to  the  pedicle  as  a  neck,  seeing  that  such 
a  term  implies  a  considerable  narrowing.  It  were  better,  perhaps, 
to  call  it  the  base  of  the  flap,  since  to  be  adequate  for  the  nourishment 
of  the  rest  of  the  peninsula,  this  portion  must  be  little,  if  any,  nar- 
rower. Slender  pedicles  and  long-drawn-out  points  to  flaps  are 
both  serious  faults,  as  they  favor  gangrene.  For  the  pedicle  to  be 
skimp,  as  to  length,  is  equally  grave.  This  means  undue  stretching 
and  constriction.  It  would  far  better  be  too  long  than  too  short, 
especially  as  more  or  less  swelling  is  to  be  expected  after  the  opera- 
tion. It  is  well  to  remember  that  the  greater  the  degree  of  torsion  of 
the  base  required  to  put  the  flap  in  place,  the  greater  the  amount  of 
shortening,  and  allowance  must  be  made  accordingly.  Indeed,  it 
were  prudent  so  to  lay  out  the  flap  as  to  necessitate  the  minimum 
torsion  in  rotation — all  things  else  being  considered-^as  this  alone 
tends  to  strangulation. 

It  pays  to  study  carefully  the  original  cicatrix,  particularly  with  the 
view  to  ascertaining  the  lines  of  greatest  strain.  Here  is  where  the 
overeffect  must  be  most  pronounced,  which  concerns  both  the  ]uepa- 
ration  of  the  lid — extensive  opening  up;  and  that  of  the  Jlap — 
surplus  width  at  the  points  indicated. 

Provisional  tarsorrhaphy  has  been  extensively  practised  as  an 
adjunct  to  blepharoplasty.  In  the  correction  of  cicatricial  ectro- 
pion, however,  where  the  re])air  is  made  with  flaps  or  grafts,  the 
procedure  so  far  from  being  of  advantage,  is  a  ])osili\c  (letrimcnl, 
in  that  it  prevents  the  getting  of  tliat  very  ])ronounce(l  primary 
overeffect  which    is  an  in(lisnensal)k'  cicnienl  of    success  in  these 


LARGE    WOLFE    GRAFT 


313 


operations.  No  doubt,  the  employment  of  it  has  had  much  to  do 
with  the  discouraging  experiences  so  many  surgeons  have  had  in 
such  surgery. 

In  order  that  the  ultimate  result  of  an  operation  for  cicatricial 
entropion,  of  the  kind  in  question,  may  be  sullicient,  not  only  must 
the  eversion  be  rectiticd,  but  the  opening  up  of  the  ellipse  whereby 
the  correction  is  brought  about,  must  be  so  extreme  that  the  border 
of  the  operated  lid  lies  considerably  beyond  that  of  its  fellow.  If  it 
be  the  upper  lid,  the  free  border  reaches  the  lower  rim  of  the  orbit; 


Fir..  210. —  Larfre  Wolfe  frraft. 


if  the  lower,  the  lid  margin  reaches  the  upj)er  corneal  limbus. 
Sutures  are  seldom  required  to  maintain  the  lid  in  position  if  these 
principles  are  observed;  and  when  put  in  may  do  more  harm  than 
good.  Neither  have  I  found  a  place  for  the  excision  of  a  gore  from 
the  free  border  that  is  so  often  referred  to.  Whatever  elongation 
of  the  edge  of  the  lid  that  may  be  present  at  the  moment,  will. surely 
disappear  in  the  healing  process. 

Figs.  210,  211  and  212  refer  to  a  case  of  total  ectropion  of  the 
lower  lid  corrected   by   the   author.      Here   the  Wolfe  graft  when 


314 


ECTROPION 


laken  from  the  arm  measured  three  by  four  inches.  The  elliptical 
bared  space  left  after  righting  the  lid  measured  one  and  one-fourth 
by  two  and  one-half  inches.  On  account  of  its  great  size  and 
weight,  where  the  upper  edge  of  the  graft  was  stitched  to  the  free 
border  of  the  lower  lid,  the  suture  ends  were  left  long  and  fastened 
to  the  forehead  by  collodionized  gauze  (Fig.  210).  Fig.  211  shows 
the  result  one  month  later.  Fig.  212  shows  the  arm  defect  and 
bracket  incisions  in  which  Thiersch  grafts  have  been  planted. 


Same  as  Fig.  210.     Result. 


The  Preparation  of  the  Flap. —Having  opened  up  to  the  fullest 

extent,  and  otherwise  i)ut  in  readiness  the  place  that  is  to  be  repaired, 
and  covered  it  with  a  pad  of  cotton,  wet  with  boric-acid  solution, 
an  exact  pattern  of  it,  as  to  size  and  shape,  is  cut  out  of  a  ])iecc  of 
sterilized  gold  beaters'  skin,  tin  foil,  or  gutta-percha  tissue.  This 
is  laid  on  to  the  integument  chosen  to  supply  the  subsidiary  tissue 
and  the  flap  is  outlined,  except  at  its  base,  with  the  point  of  a  scalpel. 
To  do  this  an  incision  is  made,  through  the  epidermis  only,  parallel 
with  the  edge  of  the  pattern  and  at  least  one-half  a  centimeter 
from  it. 


LAKC.K    WOI.KK    (.KM 


,^1S 


In  order  to  allow  for  both  the  marked  i)rimary  and  the  very 
considerable  secondary  shrinka<?e,  the  llajj  is  none  too  iarj^e  if  tlie 
area  marked  out  is  at  least  twice  that  of  the  pattern.  If  the  incision 
is  of  the  right  depth,  the  flap  will  be  defmed  by  a  tiny  line  of  blood. 
From  the  base  the  lines  that  form  the  i)edicle  arc  extended  in  the 
direction  of  the  defect.  The  incision  is  then  deepened,  until  it 
reaches  the  superficial  fascia,  i.e.,  it  includes  the  skin  and  the 
subcutaneous  fat,  and  the  whole  (adii)ose  and  all)  is  dissected  up 
by  means  of  blunt-pointed  scissors.     The  dissection   is  begun   at 


Fig.  2  12. —  Defect  in  arm  in  (a^e  pictured  in  Im^. 


the  apex,  using  forcei)s  to  hold  while  cutting.  .\s  soon  as  the  end 
is  sufficiently  loosened,  the  lingers,  clad  either  in  cots  or  gloves 
of  thin  rubber,  are  substituted  for  the  forceps.  In  this  way  there 
is  less  bruising  of  the  flap,  and  one  is  enabled  to  use  the  scissors 
with  greater  precision.  The  dissection  is  carried  well  to  the  base, 
but  the  final  fashioning  of  the  pedicle,  at  its  nearest  point  to  the 
defect,  is  left  until  the  fiap  is  turned  into  its  new  position,  so  that 


3.l6  ECTROPION 

the  incisions  may  be  so  modified  as  to  produce  the  most  favorable 
adjustment,  the  least  stretching,  etc.  The  parts  are  flooded,  from 
time  to  time,  with  quite  warm  boric  or  salt  solution.  Whatever 
bridge  of  skin  that  separates  the  two  defects  is  incised  and  retracted 
to  make  a  groove  into  which  to  countersink  the  pedicle  (inlaying). 

After  trying  and  insuring  the  fit  of  the  flap  and  pedicle,  these 
and  the  beds  in  which  they  are  to  lie  are  given  their  last  attention, 
all  bleeding  is  stopped,  all  clots  removed,  and  they  are  put  in  the 
best  possible  coaptation  throughout.  Especially  must  it  be  seen 
to  that  there  are  no  air  spaces  beneath  the  flap,  and  that  its  edges 
are  not  left  curled  under,  as  they  are  strongly  inclined  to  do.  The 
fewer  the  sutures  inserted  to  fix  the  flap,  the  better.  Their  intro- 
duction causes  injury  of  the  flap,  through  mangling  and  strangula- 
tion; also  bleeding  of  the  skin  to  which  it  is  stitched,  and  thus 
the  risks  of  failure  are  multiplied.  One  at  the  extremity  may  be 
required,  but  good  sitting  flaps  will  often  need  none  at  all,  the 
dressing  alone  sufficing  to  hold  them  in  place.  Where  the  entire 
substance  is  lacking,  it  is  necessary,  of  course,  to  unite  the  edge 
of  the  flap  to  the  conjunctiva  by  a  series  of  fine  sutures. 

It  has  been  recommended  by  high  surgical  authorities  that, 
before  fixing  the  flap  in  place,  the  edges  of  the  secondary  defect 
should  be  approximated,  lest  the  stretching  of  the  skin  around  the 
primary  defect,  consequent  upon  the  latter  procedure,  should  call 
for  a  different  disposition  of  the  flap.  To  the  writer  this  seems 
both  inexpedient  and  inconsistent,  for  the  reason  that  it  is  virtually 
making  a  nice  and  propitious  arrangement  of  the  flap — really 
the  essential  part  of  the  operation — secondary  to  the  closure  of  the 
gap  from  which  it  was  taken.  Believing,  therefore,  that  it  is  more 
conducive  to  favorable  results,  I  try  to  get  the  flap  into  position  with 
the  least  possible  delay  and  to  leave  it  undisturbed.  To  this  end,  I  at 
once  cover  it  with  the  thin  sheet  of  cotton  wet  with  warm  boric  acid 
solution  and  leave  it  thus  while  attending  to  the  flayed  space,  where, 
in  bringing  the  edge  of  skin  together,  the  undermining  and  traction 
are  so  made  as  not  to  affect  the  operated  lid.  If  absolute  union  of 
the  edges  cannot  be  brought  about  without  undue  stretching, 
a  Thiersch  or  a  Wolfe  graft  is  put  in  to  piece  out,  either  at  once  or  a 
few  days  later. 

The  dressing  consists  in  the  usual  thin  sheet  of  cotton,  wet 
with  hot  saturated  solution  of  boric  acid,  made  large  enough  to 
cover  the  whole  field  of  operation.     A  large  pad  of  dry  cotton  is 


FROM   BONE    LESIONS  317 

l)uilt  upon  this,  over  this  is  laid  a  ])iccc  of  non  absorbent  material 
like  gold  beaters'  skin  or  oiled  silk  to  pre\'ent  dryness,  and  over 
all,  the  regulation  wet  netting  bandage  (see  chapter  on  Dressings). 
It  is  better  to  occlude  both  eyes  for  the  first  forty-eight  hours,  at 
the  end  of  which  period  the  dressing  is  first  removed.  This  is  done 
under  free  irrigation  willi  warm  boric  acid  solution.  Any  sutures 
that  may  have  been  put  in  are  then  removed  and  the  bandage  reap- 
plied. From  this  time  the  unoperated  eye  may  be  left  free.  The 
other  should  be  kept  bandaged,  with  daily  changing  for  purposes  of 
cleanliness  and  inspection,  for  about  ten  days  or  until  a  new  layer  of 
epithelium  has  formed  on  the  llap.  Too  early  exposure  to  the  air 
leads  to  extra  shrinkage  and  to  dry  gangrene.  Even  after  the 
bandage  is  discontinued,  it  is  well  to  protect  the  graft  for  a  time 
by  a  film  of  sterile  vaselin. 

Ectropion  from  bone  lesions  of  the  orbit  offers  sjjecial  diffi- 
culties. Those  cases  occurring,  for  example,  as  a  result  of  fracture 
of  the  infero-temporal  rim,  with  infection,  the  formation  of  sequestra, 
caries,  etc.  It  may  be  that  both  the  outer  tables  of  the  bone — the 
one  on  the  malar,  the  other  in  the  orbit — are  destroyed,  and  be- 
tween them  is  left  a  deep  adherent  cicatrix  or  cleft.  To  excise 
the  depressed  integument  avails  nothing,  for  the  excavation  is 
promptly  repeated. 

For  this  class  of  cases,  Tripier^  has  given  an  ingenious  surgical 
procedure.  The  sunken,  scarred,  soft  parts  are  excised.  On 
opposite  sides  of  the  opening,  two  ring  flaps  are  fashioned,  each 
somewhat  greater  in  area  than  half  that  of  the  cavity,  bases  toward  it. 
These  are  turned  over,  epithelial  surfaces  inward,  i.e.,  looking 
toward  the  cavity,  and  their  edges  brought  together.  From  the 
most  available  portion  of  the  nearby  skin  is  made  a  bridge  flap, 
large  enough  to  cover  the  entire  defect,  which  is  slid  on,  and  the 
secondary  defect  closed  by  undermining  and  approximating  the 
borders.  The  latter  consists,  of  course,  of  the  raw  surfaces  of  the 
wing  flaps  plus  those  of  the  places  from  which  they  were  taken. 
By  this  method  is  sought  not  only  the  righting  of  the  lid,  but  also 
the  filling  up  of  the  cleft.  The  only  other  alternative  is  to  let  the 
scar  alone,  return  the  lid  to  its  normal  ])osition  in  the  usual  way — 
by  incision  parallel  with  its  free  border  and  dissection — and  fdl 
the  gap  with  a  flap  or  with  a  graft. 

Czermak  advises  that  after  operations  necessitating  a  moderate 

*  Rec.  d'opht.,  1890,  p.  129. 


316  ECTROPION 

loss  of  bone  in  the  orbital  rim,  the  plastic  operation  be  not  resorted 
to  at  once,  as  often  such  healing  can  be  brought  about  as  either  to 
avoid  it  altogether  or  to  require  only  a  slight  surgical  procedure, 
such,  for  example,  as  the  subcutaneous  division  of  the  adherent 
scar,  followed  by  massage.  The  same  author  remarks  that  after  the 
removal  of  an  epithelioma  or  other  malignant  growth  from  the  lids, 
the  opening  be  left  uncovered  for  a  time,  so  that  a  recurrence  may 
be  early  detected  and  promptly  dealt  with,  arguing  that,  if  hidden 
by  the  borrowed  integument,  it  could  attain  inconvenient  dimensions 
before  being  discovered.  This  might  be  well  enough  if  the  growth 
were  situated  deep  in  the  inner  angle,  where  it  could  readily  extend 
into  the  lacrimal  fossa  or  into  the  accessory  sinuses  of  the  nose. 
As  a  rule,  it  is  better  to  make  the  plastic  operation  at  the  same 
sitting. 

Buedinger's  Method  for  restoring  the  Lower  Lid  [Wicu. 
Klin.  Woch.,  1902). — Buedinger  closed  the  lid  defect  by  means  of  a 
flap  of  fibrous  cartilage  from  the  patient's  ear  by  introducing  a 
piece  of  cartilage  corresponding  with  the  piece  of  tarsus  remo\-ed. 

His  method  is  the  following:  On  the  anterior  surface  of  the  helix 
region  a  piece  of  skin  of  the  desired  size  is  cut,  then  the  knife  enters 
the  adjacent  cartilage  to  half  its  thickness  and  thus  the  anterior  half 
is  split  off  from  the  posterior  one.  The  helix  thus  being  cut  in  two 
layers  of  equal  thickness  the  anterior  one  and  the  skin  are  lifted  off 
together.  This  flap  is  used  in  two  ways.  The  helix  cartilage  always 
replaces  the  tarsus  defect  but  the  skin  is  used  in  different  ways.  In 
the  one  the  hairless  thin  skin  is  to  replace  the  conjunctiva.  In  this 
case  the  flap  is  put  into  the  gap  in  such  a  manner  that  the  raw  carti- 
lage surface  looks  forward  where  it  can  be  covered  by  a  skin  flap 
taken  from  the  neighborhood  of  the  eye.  This  is  the  original  method 
of  Buedinger. 

In  another  way  the  flap  may  be  made  to  form  the  outer  surface 
of  the  lid.  In  this  case  it  is  necessary  that  the  conjunctiva  of  the 
fornix  and  of  the  lid  has  at  least  in  part  1)ecn  saved.  Here,  also, 
the  cartilage  replaces  the  tarsus  and  the  ear  skin  takes  the  place  of 
that  of  the  lid. 

In  yet  another  and  simpler  way,  the  whole  thickness  of  the  helix 
may  be  used  to  replace  the  entire  lower  lid.  For  exam])le,  such  a  ease 
was  reported  by  Meisner,  of  Koenigberg  {Klin.  Monat.,  July,  igio), 
whose  article  was  translated  by  Alt  (Am.  Jour,  of  Oph.).  The  lid 
had  been  destroyed  by  a  carcinoma.     After  preparation  of  the  edges 


DKK.Ml 


.319 


of  skin  and  con  jiuK  li\  a  a  [)()rli()n  ol"  ihr  lulix,  of  similar  shai)i'  lo 
the  lid,  l)ul  larger,  was  txciscd  from  thr  enlirc  thickness  of  the  ear,  so 
that  the  cartilage  was  coxered  with  skin  on  l)(jlh  sides.  This  piece 
was  at  once  inserted  in  the  gap,  its  concaxe  surface  next  to  the  eye. 
The  raw  edges  were  united  most  exactly  with  the  skin  of  the  face,  and 
with  the  conjunctixa.  by  fine  sutures,  and  the  usual  dressing  ai)j)iied. 
Healing  was  })rompt,  and  the  result  excellent,  remaining  so  for  about 
two  years  during  which  the  patient  was  under  observation. 

3.  The  Method  by  Cutaneous  Grafts. — As  ap]>lied  to  i)lastic 
surgery  of  the  eyelids,  this  method  is  of  recent  date,  yet,  like  that  of 
pedunculated  flaps,  in  its  relation  to  certain  other  features,  as 
rhinoplasty,  for  example,  it  is  of  ancient  origin.  It,  too,  was 
practised  by  the  ancient  Hindu  surgeons.  The  grafts  are  referred 
to  as  dermic  or  epidermic,  according  as  they  com])rise  the  entire 
thickness  of  the  skin  or  only  the  epithelial  layers. 

Dermic  Grafts  were  first  used  in  blepharoplasty  by  Le  Fort.' 
His  earliest  attempts  were  with  pieces  of  skin  cut  from  the  arm, 
that  included  the  fat,  and  were  large  enough  to  cover  the  entire 
defect.  As  they  were  mostly  failures,  he  conceived  the  idea  that 
they  were  too  thick.  With  this  in  view,  in  subsecjuent  trials  he 
pared  down  the  grafts  at  the  back,  removing  the  adipose  and  part 
of  the  connective  tissue,  and  had  the  satisfaction  of  seeing  them 
survive. 

In  Great  Britain  and  America  the  process  was  ])0])ularized 
through  articles  by  Wolfe, ^  of  Glasgow,  in  which  he  reported  suc- 
cessful blepharoplasties  with  the  Le  Fort  method  and  gave  original 
details  as  to  technic.  The  dermic  graft  is,  therefore,  referred  to  in 
these  countries  as  the  Wolfe  graft  and  on  the  continent  of  Europe,  as 
the  Le  Fort-Wolfe.  It  may  be  added  that  the  method  has  never 
ceased  to  find  favor  in  the  eyes  of  English-sj^eaking  oj)hthalmic 
surgeons,  having  attained,  in  the  United  States,  a  specially  strong 
footing,  where  it  is  employed  with  almost  as  much  conlidence  as  is 
that  with  pediceled  tlaps.  In  truth,  it  is  often  chosen  in  ]:)reference 
to  the  latter  to  obviate  the  extra  scar  on  the  face.  Their  thickness 
or  body,  renders  them  peculiarly  fit  for  rej)lacing  loss  of  substance 
in  the  lids.  In  France  and  Germany,  however,  it  is  jiretty  gen- 
erally decried,  except  as  a  last  resort,  a  method  of  necessity  and  not 
of  choice,  i.e.,  only  em])loyed  when  suitable  material  cannot  be 
obtained,  in  the  form  of  nai)s,  from  the  neighl)oring  integument. 

'  Bull,  de  la  Soc.  de  Chir.,   1S72,  p.  -!,q. 

2  Brit.  Med.  Jour.,  1876,  and  Mod.  Times  and  Gaz.,  vol.  vii,  p.  608. 


320  ECTROPION 

Valude/  for  instance,  speaks  discouragingly  of  it,  having  operated 
seventy-seven  times,  using  Wolfe  grafts  for  the  loss  of  substance, 
with  but  fifteen  successes.  Whatever  may  have  been  the  chief 
causes  leading  to  the  failures  of  our  European  colleagues,  it  is 
certain  that  immensity  of  grafts  and  of  persevercnce  did  not  figure 
largely  among  them. 

The  habitual  vice  of  the  graft  in  question  is  shrinkage.  Its 
average  capacity  in  that  line  is  enormous,  to  offset  which  its  original 
size  must  be  proportionately  vast.  This  is  the  master  key  of  the 
situation.  Yet  knowledge  of,  and  heed  to,  this  property  do  not 
always  suffice,  even  when  accompanied  by  the  utmost  precision  in 
all  other  respects.  Here  is  where  persistence  comes  to  the  rescue. 
Some  of  the  most  gratifying  results  are  obtained  only  after  re- 
peated operations,  each  one  as  extended  and  thorough  as  its  pre- 
decessor. 

According  to  the  observation  of  C.  Garre,-  the  really  useful  part 
of  the  graft  is  limited  to  the  deeper  layers  of  the  epidermis,  and  to 
transplant  the  corium,  which  is  destined  to  undergo  connective- 
tissue  degeneration,  merely  retards  the  union  of  the  Malpighian 
portion  with  the  underlying  vascular  network  and  favors  excessive 
ultimate  contraction. 

As  a  further  proof  that  the  last  word  with  regard  to  the  dermic 
grafts  has  not  been  said — that  there  resides  therein  some  subtle 
beneficent  quality  that  will  one  day  be  regularly  utilized — cases 
can  be  cited  wherein  this  bit  of  borrowed  skin  has  neither  shrunken 
nor  degenerated,  but  has  regained  its  color,  almost  immediately 
after  being  transplanted,  and  has  not  changed  so  much  as  to  even 
shed  its  epithelium.  This  has  happened  several  times  in  my 
practice.  But  with  our  present  knowledge,  the  Wolfe  graft  is  ex- 
pected to  shrink  more  than  any  of  the  other  varieties,  both  primarily 
and  secondarily.  As  a  rough  estimate,  one  might  state  the  total 
contraction,  from  first  to  last,  at  something  like  75%.  Hence,  in 
outlining  the  graft,  the  area  inclosed  would  be  about  four  times 
that  of  the  defect  to  be  covered. 

Panas^  states  that  one  condition  particularly  favorable  to  success 
of  all  autoplasty  is  the  implantation  of  the  flap  or  graft  in  the  midst 
of  a  plaque  of  scar  tissue.  Thanks  to  the  retractile  nature  of  the 
cicatrix,  an  incision  or  opening  made  therein,  instead  of  narrowing 

'  Archiv.  d'opht.,  T.  ix,  p.  289,  18S0. 

2  Beitriige  z.  klin.  Chir.,  iv. 

3  Maladies  des  Ycux,  1894,  t.  ii,  \t.  174. 


I'KKl'AkATloN    OF    C.UAKT  ,^2  I 

or  slirinkin,^;,  actually  expands,  cwn  lo  the  extent  of  a((|uirin,^  (l()ul)le 
its  lirst  area.  Xelaton,  who  hrst  called  attention  to  tlii>  inii)orlanl 
fact,  also  observed  thai  in  order  to  j^ive  the  openinj^  this  (jualily 
the  llaj)  (or  graft)  should  rest  on  normal  tissue.  Thus  it  comes  about 
that  in  ])alpebral  autoplasty  after  burns,  for  example,  a  llaj),  a])])ar- 
cntly  inade(iuale,  may  serve  for  the  complete  reparation,  provided, 
one  takes  care  to  remove  all  scar  tissue  from  the  i)lace  it  is  to  ()ccu|)y. 
This  is  not  always  feasible,  especially  when  the  cicatrix  is  \ery 
deep  or  adherent  to  bone.  In  such  cases  some  o])erators  (Wichcr- 
kiewicz  among  them)  advise  secondary  grafting,  i.e.,  not  applying 
the  supplementary  skin  until  the  defect  is  well  covered  with  granula- 
tions. Removal  of  scar  tissue  from  the  defect  is  more  urgent 
in  graft  methods  than  in  those  with  sliding  or  pediceled  nai)s. 

The  size  of  the  graft  is  limited  only  by  that  of  the  bared  space 
it  is  to  occupy.  In  fact,  a  single  piece,  sufficiently  large,  is  preferable 
to  two  or  more  smaller  ones.  De  Wecker^  with  the  idea  of  better 
insuring  the  survival  of  the  transported  integument,  tried  cutting  it 
into  squares  whose  sides  measured  from  one-half  to  one  centimeter, 
which  were  placed  on  in  the  form  of  a  mosaic;  but  it  was  found  that 
the  small  fragments  did  not  "take"  more  readily  than  larger  ones, 
and,  moreover,  shrinkage  and  scarring  were  greater. 

Preparation  of  the  Dermic  Graft.— The  lid  defect  is  i)ut  in 
readiness  the  same  as  for  a  flap,  save  that  in  case  of  the  graft 
the  primary  effect  must  be  yet  more  extreme.  A  certain  area  of  the 
delicate,  hairless  skin  at  the  inner  side  of  the  upper  arm  or  of 
the  leg  or  thigh  is  washed  with  green  soap  and  boiled  water  and 
thoroughly  rinsed  with  boric  acid  or  salt  solution.  The  skin  over 
the  inner  border  of  the  left  bice])s  (of  right  handed  patients)  is 
probably  the  most  suitable,  all  things  considered;  yet  in  the  case 
of  a  feminine  subject  likely  to  take  ])ridc  in  bare  arms,  the  thigh 
would  be  a  better  location  for  the  scar.  The  graft  is  outlined  with 
the  aid  of  the  pattern  as  per  the  instructions  for  the  flap,  except 
that  the  ratio  of  its  size  to  that  of  the  defect  should  be  about  four- 
fold, instead  of  double,  and,  there  being  no  pedicle,  of  course  the 
pattern  is  completely  surrounded  by  the  incision.  The  usual  shape 
of  the  section  of  skin  is  that  of  an  ellipse,  or  oval  and  as  it  is  impor- 
tant that  the  long  axis  of  the  graft  coincide  with  that  of  the  defect. 
Orientation  is  facilitated  by  first  dissecting  up  the  extremities 
of  the  oval  and  putting  a  line  suture  through  each  from  the  epithelial 

1  Annal.  d'oculist.,  1872,  p.  62. 
21 


322 


ECTROPION 


side.  If  this  is  not  done  the  primary  shrinkage  is  so  great  the  moment 
the  piece  is  excised  that  it  is  then  difficult  to  place  it  properly.  As 
soon  as  one  end  is  loosened  enough,  the  cotted  or  gloved  fingers  are 
substituted  for  the  forceps  to  hold  the  piece,  and  the  entire  dis- 
section is  completed  with  the  blunt  scissors,  exercising  care  to  avoid 
injury  to  the  basilic  vein. 

Should  the  skin  on  the  inner  aspect  of  the  thigh,  just  above  the 
knee,  be  chosen,  which  is  probably  the  next  most  fitting,  cutting 
into  the  long  saphenous  vein  is  to  be  guarded  against.  These 
two  large  veins  can  be  seen  through  the  skin,  as  they  lie  just  beneath 
the  superficial  fascia. 

Unlike  the  flap,  the  graft  after  having  been  severed  is  freed  from 
all  its  adherent  fat.  It  is  then  dipped  in  boric  or  salt  solution  or 
not  as  the  judgment  of  the  operator  shall  decide,  laid  on,  according 
to  its  dimensions,  and  carefully  spread  out.  The  contained  sutures 
are  inserted  at  the  corresponding  ends  of  the  defect  and  tied. 
Additional  sutures  are  put  in  only  where  they  would  seem  to  be 
absolutely  necessary.  If,  as  often  happens,  the  graft  adjusts 
itself  nicely  to  its  new  location,  these  are  best  omitted.  The 
dressing  and  after-treatment  are  identical  with  that  described  for 
pedunculated  flaps. 

Until  the  lid  operation  is  finished  and  the  bandage  is  applied, 
a  pad  of  cotton  wet  with  sublimate  solution,  one  to  three  thousand, 
is  kept  on  the  wound  in  the  arm.  Since  before  Urban  ^  signaled 
their  abandonment  in  this  particular,  the  writer  has  never  allowed 
mercuric  solutions  to  come  in  contact  with  the  graft  nor  with  the 
operated  lid,  because  of  their  coagulating  efTect  and  the  damage 
they  inflict  upon  the  epidermis.  The  last  attention  having  been 
bestowed  upon  the  eye,  the  edges  of  the  opening  in  the  arm  are 
widely  undermined  and  approximated  by  interrupted  sutures. 
Should  this  require  undue  tension  upon  the  skin,  it  is  relieved, 
where  greatest, , by  bracket  incisions  (Fig.  212),  or,  preferably,  the 
opposite  edges  of  skin  are  approached  only  so  nearly  as  practicable, 
one  to  the  other,  and  the  gap  afterward  filled  with  a  Thiersch 
graft.  If  bracket  incisions  are  made,  the  spaces  between  their 
lips  may  be  similarly  covered.  Iodoform  powder  is  dusted  on, 
iodoform  gauze  laid  on,  then  a  pad  of  cotton,  and  over  all  a  muslin 
or  wet  netting  bandage.  Every  precaution  should  be  taken  to  prevent 
disturbance  of  both  the  eye  and  the  arm  dressings.     A  good  way  is 

1  Deutsche  Zeit.  f.  Chir.,  1892. 


DERMO-EPIDERMIC    GRAl-TS  323 

to  fix  the  bandages  in  ])lace  with  flexible  collocHon,  as  described 
under  "Eye-dressings."  It  is  well  to  fix  the  arm  in  a  sling  beneath 
the  clothing,  the  better  to  guard  against  exposure  of  its  wound, 
which  is  quite  prone  to  infection. 

The  graft  is  at  first  blanched,  but  at  tlic  end  of  twenty-four 
hours,  if  it  has  "taken,"  something  like  its  normal  tint  is  present. 
A  little  later — say  on  the  second  day — it  becomes  of  a  rosy  hue. 
About  the  end  of  the  third  day  begins  the  shedding  of  its  epithelium, 
when  it  again  appears  whiter.  After  this  process  is  completed  the 
patch  takes  on  a  color  that  is,  for  a  time,  redder  than  that  of  the 
surrounding  skin,  but  its  ultimate  color  is  a  shade  whiter  than  that. 
If  the  transplanted  tissue  or  any  part  thereof  perish,  it  may  be 
from  one  of  several  causes,  chief  among  which  are  gangrene  (white, 
livid,  or  dry),  secondary  hemorrhage  beneath,  stitch-canal  or  super- 
ficial infection,  phlegmon,  and  erysipelas.  These  are  all  accidents 
that  either  happen  very  early  or  not  at  all.  A  later  sequel,  coming 
sometimes  many  days  after  the  graft  has  become  viable,  is  a  progres- 
sive ulceration.  For  sloughing,  hemorrhage,  and  gangrene,  little 
can  be  done.  Infections  are  to  be  treated  by  removal  of  sutures, 
copious  and  frequent  irrigations  with  mild  antiseptic  solutions  used 
quite  warm,  etc.  An  excellent  remedy  for  the  ulceration  alluded 
to  is  the  painting  of  the  raw  surface  with  a  12%  solution  of  silver 
nitrate,  followed  by  thorough  washing  with  warm  salt  solution. 

Epidermic  and  Dermo-epidermic  Grafts. — The  epidermization 
of  parts  denuded  of  skin  was  first  conceived  and  accomplished  by  the 
distinguished  surgeon,  Reverdin,^  of  Geneva.  To  assist  and 
hasten  the  healing  of  certain  indolent  varicose  ulcers,  Reverdin  cut, 
with  a  lancet,  from  the  skin  of  a  limb,  epidermic  flaps,  which  he 
subdivided  into  bits  containing  only  a  few  square  millimeters,  and 
deposited  them  on  the  granulating  surface  in  the  form  of  small 
disseminated  islands.  It  was  demonstrated  that  the  method  stimu- 
lated the  cicatrization  in  raw  surfaces  of  limited. extent,  but  was 
less  efficacious  for  larger  ones. 

To  better  meet  the  latter  condition.  Oilier^  made  the  grafts 
of  considerable  size — ten  to  fifteen  millimeters  long,  by  one  to 
three  millimeters  wide — and  purposely  included  a  portion  of  the 
corium  {dermo-epidcrmic  graft).  He  carefully  removed  all  cicatricial 
tissue  in  the  preparation  of  the  defect  to  be  repaired,  and  waited 

1  Bull,  de  la  Soc.  de  Chir.,  1869. 

2  Comptes  rendus  de  I'Acad.  des  Sciences,  1872. 


324 


ECTROPION 


for  the  surface  to  granulate  before  applying  the  graft.  The  latter 
was  held  in  place  by  strips  of  diachylon  plaster.  This  species  of 
cutaneous  graft  was  first  employed  in  blepharoplasty  by  Lawson.i 
In  preparing  it,  the  skin  may  be  separated  from  its  original  location, 
as  directed  for  the  Wolfe  graft,  and  then  pared  down  very  closely 
with  a  razor,  cutting  well  below  the  epidermis.  Thiersch^  adopted 
the  method  of  Oilier,  but  with  certain  modifications,  the  most 
important  among  which  was  that  he  declined  to  implant  the  graft 
upon  a  granulating  surface  {secondary  grafting),  placing  it  rather 
upon  a  freshly  prepared  raw  one  (primary  grafting).  If  granula- 
tions were  already  present,  they  were  shaved  off  to  conform  to  the 
principle  in  view.  This,  according  to  the  same  author,  ^  is  that 
granulations  make  an  unfavorable  base  for  the  transplanted  integu- 
ment, for  the  reason  that  they  of  themselves  produce  a  layer  of 
scar  tissue.     He  also  made  the  pieces  thinner  than  did  Oilier. 

Eversbusch-i  advised  that  this  form  of  graft  be  cut  as  thin  as 
possible— translucent  in  fact— the  blade  of  the  knife  or  razor  show- 
ing through  during  the  section.  This  constitutes  the  true  epidermic 
graft,  known  in  this  country  under  the  name  of  Thiersch  and  in 
Europe  under  that  of  Thiersch-Eversbusch.  While  it  is  less  effective, 
owing  to  its  lack  of  body,  for  the  restoration  of  the  lid  than  the 
Wolfe  graft,  it  has  the  advantage  in  most  instances  of  shrinking 
less.  In  point  of  ability  to  survive,  the  two  varieties  would  seem 
to  be  about  on  a  par. 

Whether  concerned  immediately  in  the  lid  operation  or  not,  the 
transplanting  of  epidermis  will  often  be  found  a  valuable  adjunct 
thereto,  as,  for  example,  to  make  a  patch  when,  after  a  few  days,  a 
flap  or  dermic  graft  chances,  through  ulceration  or  other  mishap, 
to  have  its  epithelium  destroyed  or  when  an  unavoidable  gap 
remains  in  a  secondary  defect. 

The  Thiersch  method  is  as  follows:  the  primary  defect  having 
been  prepared  as  for  the  flap  of  the  Wolfe  operation  (or  if  granula- 
tions are  present,  they  are  removed),  the  inner  side  of  the  upper  arm 
or  of  the  lower  third  of  the  thigh,  is  washed  with  soap  and  sterile 
water,  rinsed  with  lM)ric  acid  solution  and  thoroughly  dried  with 
gauze — not  with  cotton,  on  account  of  the  loose  fibres  that  cling  to 
the  parts.     The   tliigh   ofl'ers   fewer  diniculties  to   the  cutting  of 

'Lancet,  Nov.  iq,  1870. 

2  Berlin,  klin.  Woeh.,   1874. 

'  Arch.  f.  klin.  Chir.,  Bd.  xvii,  2,  S.  318,  ff. 

4  Muncli.  nicd.  Woch.,   1887,  Nr.  1,  u.  2. 


HOTZ  S    METHOD  325 

the  L^raft  ])ccause  of  its  slight  convexity,  and  nii_i^hl  be  jjreferable  to 
the  patient  as  tlie  site  of  liie  resulting  scar.  The  chosen  skin  is 
put  moderately  upon  the  stretch,  while  with  a  keen,  lonj,'  hladed 
razor,  that  has  been  thoroughly  boiled,  enough  of  the  epidermis  is 
shaved  oiT-  -if  possible,  in  one  piece— to  cover  the  entire  defect.  It 
greatly  facilitates  the  severing  of  the  graft  to  have  both  the  razor 
and  the  skin  perfectly  dry,  and  the  lower  side  of  the  blade  anointed 
with  sterile  \aseline  or  castor  oil.  The  blade  is  held  flat  and  firm  and 
the  cutting  is  accom])lishe(l  l)y  a  long,  slow,  sawing  motion.  When 
properly  done,  the  blade  of  the  razor  can  be  seen  through  every  part 
of  the  graft,  and  the  resulting  raw  surface  is  thickly  speckled  over 
witli  tiny  bleeding  points  that  mark  the  spots  where  the  tips  of 
the  more  i)rominent  papilke  have  been  cut  off.  To  cause  the  skin 
to  present  a  flat  surface  to  the  razor  I  have  profited  by  an  ingenious 
suggestion  of  AI.  I>.  Harris,  of  Chicago,  whereby  a  straight-edged 
object,  such  as  the  lid  of  a  cigar-box,  is  dragged  along  in  advance 
of  the  razor.  The  graft  is  at  once  laid  on  wdiere  needed,  without 
previous  dipping  into  boric  or  salt  solution,  and  slid  directly  from 
the  razor  on  to  the  defect.  Here  it  is  nicely  spread  out,  after  which 
any  overlapping  edges  are  trimmed  with  the  scissors  to  lit.  Few, 
if  any,  sutures  are  put  in.  The  usual  dressings,  comprising  a  thin 
lamina  of  cotton,  wet  with  hot,  saturated  solution  of  boric  acid, 
next  to  the  skin,  a  thick  pad  of  dry  cotton  so  built  on  as  to  pre\ent 
undue  pressure  on  the  graft,  over  this  a  generous  piece  of  gold  beater's 
skin,  tin  foil,  or  gutta-percha  tissue,  and  over  all  the  wet  netting 
bandage,  fastened  on  with  flexible  collodion. 

For  fear  of  carrying  syphilitic,  or  other  infection,  grafts  ought 
never  to  be  taken  from  another  individual  if  they  can  be  gotten 
from  the  patient. 

An  effecti\'e  method  for  the  disposition  and  fixation  of  cutaneous 
grafts  in  operations  for  cicatricial  ectropion  is  that  of  Hotz.^  In 
order  to  prevent  the  shrinkage  of  the  graft  from  acting  with  full 
force  upon  the  free  border,  he  divides  the  wound  area  into  two 
sections,  one  representing  the  bared  surface  of  the  lid  proper  and  the 
other  that  beyond  the  lid,  each  of  which  he  covers  with  a  separate 
Thiersch  (or  Wolfe)  graft.  The  lid  graft  is  anchored  by  sutures 
to  the  strip  of  skin  at  the  free  border  of  the  tarsus  (upper  lid)  or  to 
the  tarso-orbital  fascia  beneath  the  tarsus  (lower  lid).  The  second 
division  of  the  bared  space  is  then  covered  by  an  unsutured  graft. 

1  Archives  of  Ophthalmology,  vol.  xxxii.  No.  3,  IQ03. 


^26 


ECTROPION 


Before  implanting  the  grafts,  two  strong  silk  threads  are  put 
through  the  edge  of  the  reposited  lid,  it  is  made  to  widely  overlap 
its  fellow,  and  the  threads  are  fastened  to  the  cheek  (or  brow)  by 
collodionized  cotton  or  gauze.  By  thus  fixing  the  edges  of  the  lid 
graft  to  firm  supports,  both  its  shrinkage  upon  itself  and  its  traction 
upon  the  free  border  are  counteracted.  Moreover,  by  this  arrange- 
ment, the  contraction  of  the  ultratarsal  graft  is  not  so  directly 
transmitted  to  the  tarsal  one. 


±-^ 


Hoiz. 


Fig.  214. — Hotz. 


In  some  instances,  Hotz,  instead  of  transplanting  a  graft  to 
cover  the  tarsal  portion,  utilizes  the  cicatricial  skin  already  overly- 
ing it,  which  he  dissects  up  in  the  form  of  a  semilunar  Hap  that  is 
left  adherent  along  the  lid  margin.  The  bands  of  scar  are  divided, 
the  lid  is  turned  into  position,  drawn  over  its  fellow,  and  fixed 
by  ligatures  and  collodion  as  just  described.  If  it  be  the  upper 
lid,  the  free  border  of  the  flap  is  stitched  to  the  upper  border  of 
the  tarsus;  if  the  lower,  to  the  tarso-orbital  fascia  and  the  remain- 
ing wound  surface  is  covered  by  a  Thiersch  graft  into  which  no 
sutures  are  ]nit.  If  there  is  decided  elongation  of  the  free 
border,  a  ])ortion  is  resected  at  the  outer  canthus  (sec  Figs.  213 
and  214). 

4.  The  Italian  method,  or  auloplasty  by  means  of  a  pedic'eled 
llap  taken  from  a  distant  pari  of  the  body.  This,  like  blepharo- 
plasty  by  cutaneous  grafts,  is  api)lical)k'  lo  cases  where  llie  destruc- 


ITALIAN    METHOD  527 

lion  of  the  lids  and  the  adjacent  skin  is  such  as  to  render  the  use 
of  the  local  integument  impossible  or  undesirable.  The  method  was 
invented  several  centuries  ago  by  a  Sicilian  surgeon  of  the  name 
Branca,  and  ])racticed  by  himself,  and  afterward  by  divers  other 
members  of  the  same  name  and  family  for  the  restoration  of 
the  nose.  It  has  also  been  known  as  the  Tagliacotian  method, 
in  honor  of  Gaspard  Tagliacozzi,  who,  in  1597,  wrote  a 
treatise  on  it. 

It  consisted  in  i)rei)aring  the  part  to  be  reconstructed  and  loosen- 
ing a  tongue  of  skin  from  some  available  portion  of  the  arm  or 
hand.  After  granulation  was  well  established  in  both  defects,  the 
Hap  was  brought  into  position  by  binding  the  member  bearing  it 
securely  to  the  head.  Owing  to  the  length  of  time  required  for  the 
granulations  to  appear,  added  to  that  for  the  healing  process,  and 
to  the  great  inconvenience  occasioned  the  patient,  the  proceeding 
was  abandoned.  In  1816,  however,  it  was  rescued  from  oblivion  by 
Carl  Ferdinand  Graefe,  who  employed  it  in  a  modified  form  for 
blepharoplasty.  Among  other  improvements,  this  surgeon  hit  upon 
that  of  putting  the  flap  into  place  at  once  without  waiting  for  the 
granulation  of  the  surfaces  to  be  united.  The  method  has  found 
scant  favor  in  the  eyes  of  modern  surgeons,  still  less  in  those  of 
their  patients.  In  this  country  it  has  been  resorted  to  with  success 
by  R.  H.  Derby  1  to  replace  the  lids  lost  in  an  extensive  burn  of 
the  face. 

Still  more  recently  it  has  been  revived  in  France  by  Prof.  Paul 
Berger,-  the  Parisian  surgeon.  In  this  admirable  report,  among 
much  else  of  interest.  Professor  Berger  details  four  cases  in 
which  he  applied  the  Italian  method  to  blepharoplasty.  In  three  of 
them  the  reparation  concerned  the  lower  lid,  and  in  the  fourth  both 
the  upper  and  the  lower.  In  the  last  case,  death  occurred  from 
iodoform  poisoning  on  the  day  previous  to  tliat  which  was  set  for 
the  severing  of  the  pedicle. 

Mode  of  Operation  (Berger). — An  exact  pattern  of  the  lid  defect 
is  cut  out  of  oil  silk  or  court  plaster,  the  arm  is  approached  to 
the  eye,  and  the  point  that  makes  the  easiest  and  most  natural  con- 
tact is  marked  in  ink,  as  the  site  of  the  pedicle.  The  pattern  is 
then  laid  on  in  such  a  manner  ihal  the  pedicle  will  be  neither 
twisted,  stretched,  nor  compressed,  and  so  outlined  tlial  the  area  of 

1  Trans,  of  the  Am.  Oph.  Society,  1885,  p.  141. 

'^  Cong.  fran.  de  Chir.  seance  du  9  otobre,  18S9,  4  session,  p.  361. 


328 


ECTROPION 


the  lla})  will  be  one-fourth  to  one-third  greater  than  that  of  the 
model.  The  subcutaneous  fat,  as  well  as  the  superficial  fascia,  are 
included  with  the  skin.  Near  the 
pedicle,  the  ajjoneurosis  is  slightly 
raised  in  order  that  the  nourishing 
vessels  may  be  free  from  pressure. 
All  the  wounded  vessels  of  any  size 
are  tied. 

After  many  trials  Berger  adopted, 
as  the  fixing  apparatus,  a  leather 
corset  provided  with  a  collar  and 
cap,  all  articulated  by  laces  and 
straps  and  strengthened  by  steel 
braces.  A  laced  leather  gauntlet,  ex- 
tending from  the  hand  to  a  point 
above  the  elbow,  put  on  and  strapped 
to  the  cap,  holds  the  arm  firmly  to  the 
head  (Fig.  215).  Numerous  fine, 
superficial,  silk  sutures  are  put  in  to 
hold  the  flap  while,  near  the  pedicle, 
a  few,  deep,  strong  ones  are  inserted 
Salol,  boric  acid,  or  iodoform  powder 
(the  last  used  guardedly)  is  dusted  into  the  nooks  and  upon  the 
other  parts.  Over  this,  gauze  or  a  thin  layer  of  cotton,  wet  with 
boric  acid  solution;  on  this,  padding  of  cotton,  and  overall  a  bandage. 
Liquid  food  and  constant  w^atching  by  an  attendant.  Quiet 
in  bed  for  four  or  five  days,  then  propped  up  for  a  short  time  at 
intervals.  After  a  week,  sitting  in  an  easy-chair,  and  eyen  walking 
cautiously  about  the  room.  The  pedicle  is  divided  near  the  end  of 
the  second  week. 

In  order  to  accustom  the  patient  to  the  constrained  posture  and 
to  the  manner  of  performing  such  functions  as  sleep,  alimentation, 
evacuations,  etc.,  as  well  as  to  test  the  immobility  of  the  parts 
concerned  in  the  blepharoplasty,  it  is  well  to  have  him  wear  the 
apparatus  for  a  few  days  before  the  operation. 


15. — Berger's  method. 

to  aid  in  resisting  traction. 


CHAPTER  YIII. 
OPERATIONS  UPON  THE  CONJUNCTIVA. 

SYMBLEPHARON. 

Literally,  this  term  means  an  adhesion  or  a  clinging  together 
of  the  eyelids  In  its  true  sense,  however,  it  refers  to  a  union 
of  the  palpebral  with  the  ocular  conjunctiva,  or  to  the  severer  con- 
dition wherein  the  lid  is  firmly  adherent  to  the  globe,  .\mong  the 
more  frequent  causes  are  burns  from  lime,  molten  metal,  acids,  etc. 
Owing  to  gravitation  and  to  the  exposed  situation  of  the  lower  ])art 
of  the  conjunctival  sac,  it  is  more  often  affected  than  is  the  upi)er. 
The  extent  of  the  adherence  varies  from  that  of  a  tiny  isolated 
bridge  to  that  in  which  all  traces  of  a  cul-de-sac  are  lacking,  and 
the  entire  inner  aspect  of  the  lid  is  united  to  the  ball.  Symble- 
pharon  is  designated  as  outward,  inward,  upivard,  and  downward, 
according  to  its  location.  For  convenience  in  reference,  the  dilTerent 
grades  are  classified  as  follows: 

1.  Symblepharon  anterius,  commonly  s])oken  of  as  circum- 
scribed, is  the  simplest  form,  and  is  so  named  because  the  junction 
between  the  opposing  portions  of  conjunctiva  does  not  reach  the 
fornix. 

2.  Symblepharon  Posterius,  Partial  Symblepharon.— This 
class  comprises  the  intermediate  grades,  or  those  in  which  the 
attachment  extends  to  the  fornix,  but  in  which  the  cul-de-sac  is 
not  wholly  obliterated,  nor  is  there  marked  cicatrization  of  the  bulbar 
conjunctiva. 

3.  Symblepharon  Totalis,  Complete  Symblepharon.— Under 
this  heading  are  included  all  the  more  pronounced  cases  where  the 
attachment  involves  the  whole  of  one  or  both  lids,  and  the  cul-de-sac 
is  utterly  eft'aced.  In  the  exaggerated  instances  there  is  often 
ankyloblepharon  also.  Some  authors  (Fuchs  among  them)  state 
that  blindness,  or  at  most,  quantitative  perception  of  light,  is  a 
necessary  accompaniment  of  total  symblepharon.  This  is  by  no 
means  true  of  the  commonest  form,  viz.,  that  in  which  the  entire 

329 


330  OPERATIONS  UPON  THE  CONJUNCTIVA 

lower  lid  is  grown  to  the  globe,  even  when,  as  often  happens,  the 
conjunctival  adhesion  covers  the  greater  portion  of  the  cornea;  nor 
is  it  invariably  true  of  that  in  which  both  lids  are  attached  through- 
out. Though  in  many  instances  sight  has  been  restored  only  by 
the  additional  operation  of  iridectomy.  Surgical  intervention  is 
a  crying  need  in  all  cases,  whether  blindness  exists  or  not.  Among 
the  objects  sought  are  greater  motility  of  lids  and  globe,  better 
vision,  relief  from  pain,  improved  appearance,  and  the  making  of  a 
socket  for  the  wearing  of  a  prothesis. 

The  same  principles  are  concerned  in  operations  for  symblepharon 
as  in  those  for  blepharoplasty,  and  the  means  are  also  similar, 
viz.,  by: 

A.  Sliding  flaps  of  conjunctiva. 

B.  Pediceled  flaps  of  conjunctiva  or  skin. 

C.  Mucous  or  cutaneous  grafts. 

A  and  B  refer  to  autoplasty  only;  C  to  autoplasty,  heteroplasty, 
and  zooplasty.  No  intervention  is  admissible  while  contraction  is 
still  active  in  the  adhesions. 

1.  The  surgical  treatment  of  the  first  group  (symblepharon 
anterius)  presents  no  special  difficulties.  It  usually  suffices,  for 
the  narrow  bridges,  merely  to  cut  them  with  blunt  scissors,  or 
with  a  blunt  bistoury  and  grooved  director,  and  to  watch  for  reat- 
tachments which,  occurring,  are  at  once  broken  loose  with  a  probe. 
If  the  division  of  the  symblepharon  leaves  a  decided  opening  in  the 
ocular  conjunctiva,  fine  silk  sutures  are  put  in  to  close  it.  If  a 
tag  of  the  mucosa  is  left  hanging  to  the  lid,  it  is  not  severed  until 
after  the  healing  of  the  bulbar  wound.  If  the  bridge  is  fast  to  the 
cornea,  the  latter  is  first  freed  by  careful  dissection.  In  cases  where 
the  defect  is  so  large  as  to  cause  undue  stretching  of  the  conjunctiva, 
in  closing  it  Arlt  advised  the  making  of  a  bracket  or  relaxing  incision 
on  either  side. 

2,  The  handling  of  the  second  class  of  cases,  or  partial  symble- 
pharon, is,  in  the  main,  attended  with  great  satisfaction,  though 
they  often  call  for  much  planning  and  perserverence.  The  easiest 
to  deal  with  and  the  most  frequently  encountered  is  what  is  known 
as'^the  columnar  form,  in  which  a  tliin,  or  rclati\'cly  thin,  bridle 
uniting  the  lid  and  globe  reaches  into  the  fornix  and  many  times 
implicates  the  cornea.     When  it  occupies  the  up])er,  lower,  or  outer 


AlU/r  S    METHOD 


M^ 


P^iG.  2i6. — Arlt's  operation. 


cul-(lc-sac,  ihc  operation  usually  adoijlcd  is  thai  of  v.  Aril.'  Manner 
of  doing  it  :  Jf  the  conjuncti\a  is  fast  to  the  cornea,  the  so  called 
pterygoid      symblcpharon,      the  ^  y^c^y^- 

apex  of  the  adhesion  is  held  with  /'^y^/^^^^ 

delicate  sharp-toolhcd  forceps, 
and  the  dissection  made  with  the 
bulge-edged  scalpel.  To  aid  in 
this  step,  some  surgeons  lirst  put 
a  suture  through  the  apex  to 
hold  by.  If  this  is  done,  the 
thread  should  be  double-armed 
and  so  inserted  as  to  make  the 
loop  lie  crosswise,  near  the  tip 
of  the  apex,  and  u|)on  the  out- 
side, so  that  the  same  suture 
may  be  used  at  a  later  stage  of 
the  operation.  As  this  means 
difficulty  to  avoid  cutting  the 
thread,  it  is  better  to  dispense  with  the  procedure. 

Having   passed   the  limbus,   the   dissection   is   carried   on   with 
small,  blunt,  curved  scissors  to  the  very  bottom  of  the  cul-de-sac — 

really  farther,  as  a  rule,  than 

mr"" 


to  the  limits  of  the  fornix.     An 

incision    is    then    made    with 

straight     blunt    scissors,     on 

either  side  of  the  bridle  and 

close  to  it,  from  apex  to  base, 

if  practicable,  converging  the 

two  near  their  ends.     If  the 

double-armed  suture  has  not 

already  been  put  into  apex  as 

described,  this    is  now  done, 

the  pocket  at  the  base  of  the 

flap  is  pulled  wide  open,  the 

needles  inserted  at  its  bottom, 

brought  out  through  the  skin, 

side  by  side,  and  tied  over  a  cylinder  of  gau/.e.     The  edges  of  the 

bulbar  opening  are  undermined  and  united  by  fme  silk  sutures,  the 

knots  of  which  are  not  too  tightly  tied  (Figs.  216  and  217). 

1  Graefe-Saemisch,  Bd.  iii,  1874,  S.  43Q. 


Aril's  operation. 


332 


OPERATIONS    UPON    THE    CONJUNCTIVA 


Teale-Knapp  operation. 


When  the  loosening  of  the  hd  from  the  eye  leaves  a  defect  too 
broad  to  be  covered  by  simple  lateral  mobilization  of  the  mem- 
brane, pedunculated  flaps  are 
fashioned  from  a  part  some- 
what further  away  and  turned 
in  to  till  the  gap — a  method 
first  practised  by  Teale.^  In 
detaching  the  symblepharon, 
if  only  its  point  involved  the 
cornea,  this  surgeon  made  an 
incision  across  the  growth,  at 
the  limbus,  and  left  the 
corneal  portion  which  was 
supposed  to  dwindle  away 
from  atrophy.  The  rest  he 
separated  in  the  usual  way 
and  (in  downward  symbleph- 
aron) took  a  vertical  flap 
from  either  side  of  the  cornea 
(Fig.  218);  the  two  were  disposed  one  above  the  other  on  the  de- 
fect, to  cover  it,  stitched  together,  and,  also,  to  the  cut  edge  of  the 
pterygoid  above,  and  to  the  lid 
flap  below.  The  secondary  de- 
fects were  closed  by  simply 
drawing  the  conjunctiva  to- 
gether by  sutures  (Fig.  219). 
Teale,2  at  a  later  period,  made 
an  arched  bridge  flap  from  the 
lateral  and  upper  conjunctiva 
which  he  slid  down  over  the 
cornea,  and  stitched  into 
position,  to  fill  the  opening  left 
by  cutting  away  of  a  downward 
symblepharon. 

Knapp^  combines  the  method 
of  Teale  with  that  of  Arlt.  In 
downward  attachment  with  corneal  ])oint,  for  example,  he  frees 
the  cornea  and  separates  the  lid  to  its  base,  turns  tlie  llap  tluis 
'  Ophthalmic  Hospital  Reports,  Oct., 


Fu;.  219. — Teale-Knap 


Report  of  Fourtli  Internat.  Cong,  of  Oph 
Graefe's  Arch,  xiv,   i,  1868,  p.  270. 


Lone 


[87,:;, 


SYMBT.F.rTr.\TU)X  ^_^T, 

formed  down,  an<l  fixes  it  into  the  cul-dc-suc  by  the  doublc-armcd, 
externally-tied  suture  of  Aril.  He  also  arranges  the  (laps  as  did 
Teale  and  in  order  to  keep  them  from  riding  up  onto  the  corneal 
defect,  sutures  the  lower  one  to  the  submucous  tissue  of  the  fornix. 

In  a  case  where  the  removal  of  a  very  large  pterygoid  symble- 
pharon  caused  the  loss  of  considerable  of  the  corneal  substance, 
Schrimer,  to  prevent  a  corresponding  opacity,  successfully  grafted 
on  to  the  ])lacc  small  lamellae  taken  from  the  cornea  of  a  rabbit. 

Inward  or  outward  symblepharon  often  affects  both  lids,  and  is 
attended  by  ankyloblepharon.  As  an  example  of  surgical  correction 
of  inward  symblepharon  with  ankylosis,  the  following  method,  after 
Langier  (i860)  and  Arlt  (1870),  is  cited.  Supposing,  as  is  fre- 
quently the  case,  there  is  obliteration  of  the  internal  fornices,  and  a 
broad  band  of  skin  unites  the  inner  thirds  of  the  lids.  A  horizontal 
incision  is  made,  midway  of  the  band,  from  its  outer  limit  to  the 
inner  commissure;  the  symblepharons  are  detached,  a  double-armed 
suture  is  put  into  each  of  the  resulting  flaps,  they  are  turned  into 
their  respective  cul-de-sacs,  and  fixed  by  tying  the  threads  over 
cylinders  on  the  outer  skin. 

In  the  event  of  the  primary  injury  having  been  deep  in  the  fornix, 
it  is  best  to  excise  as  much  as  is  expedient  of  the  scar,  for  it  is  the 
inevitable  pushing  upward  of  this  buried,  inodular  mass  that  is  the 
undoing  of  many  an  otherwise  excellent  result.  To  prevent  these 
relapses,  Panas  tried  carrying  the  apex  of  the  detached,  downward 
symblepharon  out  through  a  slit  made  through  the  base  of  the  lower 
lid,  and  suturing  it  to  the  cheek;  but  with  poor  success. 

3.  To  attempt  the  relief  of  total  symblepharon  is  always  an 
arduous  undertaking,  and  often  a  hopeless  one.  Baudry  says  of  it, 
'7(7  (lire  de  symblepharon  reste-l-elle  un  des problhnes  les  plus  difficiles 
de  la  (hirurgie  oculaire,''  and  Knapp  speaks  even  more  discouragingly, 
to  wit,  "The  value  of  a  symblepharon  operation  depends  upon  the 
extent  of  conjunctiA'al  surface  that  is  preserved."  He  intimates 
that  he  believes  with  Arlt  that  cases  of  total  atrophy  (symblepharon) 
are,  for  the  surgeon,  a  noli  me  tangcre.  And  Fuchs  flatly  asserts 
that  "cases  of  extensive  symblepharon  posterius  and,  obviously, 
those  of  symblepharon  totalis,  are  incurable."  It  is  a  relief  to  know 
that  the  gloomiest  of  these  gloomy  views  arc  not  altogether  war- 
ranted by  the  present  status  of  the  surgery  in  question  and,  as  it  has 
now  been  some  years  since  the  two  last-mentioned  eminent  men 
expressed  their  opinions,  it  may  be  pretty  safely  assumed  that  they. 


334  OPERATIONS    UPON    THE    CONJUNCTIVA 

too,  have  come  to  regard  the  matter  in  a  more  favorable  hght. 
That  perfectly  satisfactory  results  can  be  obtained  in  many  of  the 
most  unpromising  cases  of  total  symblepharon  has  been,  during  the 
past  ten  years,  positively  and  repeatedly  demonstrated.  It  must 
be  borne  in  mind,  however,  that  a  single  operation  will  seldom 
suffice.  The  happiest  issues  have  often  come  only  after  several 
interventions. 

It  were  bootless  to  attempt  the  description  of  any  considerable 
number  of  the  myriad  surgical  measures  that  have  been  devised  for 
the  higher  degrees  of  symblepharon,  for  the  reason  that  the  vast 
majority  of  them  have  availed  nothing.  It  will  serve  better  to  call 
attention  to  a  few  that  have  proven  more  or  less  effective.  The 
separating  of  the  lid  from  the  globe  is  usually  a  simple  affair — to 
keep  them  separate  is  the  perplexing  thing.  Obviously,  this  can  be 
done  only  by  interposing  two  leaves  of  tissue  that  will  unite  readily, 
one  with  the  inner  surface  of  the  lid  and  the  other  with  the  cor- 
responding surface  of  the  globe,  yet  remaining  distinct  as  regards 
their  own  opposing  faces.  To  this  end  have  been  employed:  (i) 
mucous  grafts  taken  from  the  mouth,  from  the  fellow  eye,  or  that 
of  another  person,  from  the  vagina,  from  the  eyes  of  rabbits,  hares, 
and  dogs;  (2)  flaps  of  skin  turned  in  from  adjacent  parts  of  the  face, 
and  (3)  cutaneous  grafts  after  the  methods  of  Wolfe  and  Thiersch. 

I.  Mucous  grafts  undoubtedly  afford  the  most  suitable  material 
with  which  to  replace  the  lost  conjunctiva,  especially  when  the 
cornea  is  intact  or,  rather,  when  the  eye  is  capable  of  useful  vision. 
Epidermis  is  always  irritating  to  the  cornea.  It  may  be  from  its 
harshness,  from  dryness,  because  of  its  oily  surface,  or  from  con- 
tained hairs,  etc.,  and  although  its  character  does  change  in  time 
so  as  to  partake  more  of  the  nature  of  mucous  membrane,  it  never 
entirely  ceases  to  be  dermic,  and  requires  to  be  frequently  cleansed 
of  dead  epithelium.  Moreover,  mucous  grafts  are  not  only  more 
suitable  from  a  physiologic  standpoint,  better  tolerated  by  the  eye, 
etc.,  but  they  are  more  available  since  they  may  be  furnished  by 
the  lower  animals.  Unhappily,  they  are,  perhaps,  the  least  fitting 
from  a  surgical  standpoint.  Not  that  they  do  not  take  promptly, 
but,  for  one  reason,  because  of  their  exceeding  frailty  and  tender- 
ness, which  renders  them  incapable  of  holding  the  retaining  sutures. 

The  originator  of  this  species  of  grafting  was  Wolfe, ^  of  Glasgow, 
who  in  1872  made  use  of  the  rabbit's  conjunctiva.     A  little  later 

>  Annal.  d'oct.,  t.  60,  p.  i  21-126,  1873. 


SYMBLEPIIAROX  335 

(1873)  StcUwag,  of  Vienna,  experimented  with  the  same,  also 
with  mucosa  from  the  mouth  and  from  the  va<,M"na.  The  rabbit's 
conjunctiva  has  been  tried  by  hundreds  since  then,  f,'cnerally 
with  some  degree  of  immediate  success,  but  the  uUimate  resuUs  have 
been  uniformly  disappointing.  Thinking  to  profit  by  its  greater 
toughness,  Panas'  essayed  the  effect  of  transplanting  the  conjunctiva 
of  the  dog — to  no  purpose.  Just  as  with  that  of  the  rabbit  and  the 
mucosae  of  man,  there  ensued  a  gradual  pushing  up,  or  shallowing 
of  the  cul-de-sac  till  at  the  end  of  a  few  months — nothing.  After 
a  day  or  two  the  epithelium  comes  off,  and  two  granulating  surfaces 
are  found  in  contact,  and  neither  the  insertion  of  an  artificial  eye, 
a  plate  of  metal,  nor  any  known  force  will  stop  the  relentless  prog- 
ress of  the  obliteration. 

It  is  not  improbable  that  some  one  will  ere  long  hit  upon  the 
much-hoped-for  method  of  permanently  relieving  symblepharon  by 
the  transplantation  of  mucous  membrane.  When  this  is  found,  it 
is  likely  that  conjunctiva  of  some  kind  will  be  the  mucosa  selected, 
on  account  of  its  appropriate  texture,  the  other  kinds  being  far  too 
meaty. 

The  method  pursued  has  usually  been,  first,  to  detach  the 
symblepharon  completely,  to  copiously  irrigate  the  cavity  with  salt 
or  boric  solution,  stop  all  bleeding,  and  then  cover  the  lids  with  a 
pad  wet  with  the  same  solution.  If  the  rabbit's  conjunctiva  is 
chosen,  it  is  better  to  have  ready  two  of  them,  in  case  of  an  accident 
to  the  first  one  used.  The  animal  is  chloroformed,  its  eye  cleansed 
with  the  salt  or  boric  solution,  two  or  several  sutures  are  put  into 
the  conjuctiva  through  small  cuts,  by  which  the  area  to  be  excised 
is  marked  off  and  by  which  also  the  piece  is  managed  after  de- 
tachment. If  this  is  not  done,  it  is  next  to  impossible  then  to  tell 
front  from  back.  The  lid  to  be  repaired  is  pulled  far  away  from 
the  globe,  the  latter  is  rotated  strongly  upward  (the  operation  being 
for  a  downward  symblepharon),  the  borrowed  piece,  with  or  with- 
out previous  dipping  in  the  warm  solution,  laid  in  right  side  out, 
the  contained  sutures  fastened  to  the  surrounding  tissue,  and  as 
many  others  put  in  as  are  needed. 

To  finish,  loop  threads  are  put  down  through  the  middle  of  the 
graft,  brought  out  on  the  cheek  and  tied  over  cylinders  of  gauze  to 
form  the  cul-de-sac.     Some  operators  wait  for  these  to  cut  out.     It 

1  Mai.  des  Yeux,  t.  ii,  p.   iSi. 


336  OPERATIONS    UPON    THE    CONJUNCTIVA 

is  a  good  plan  lo  lay  on  a  piece  of  sterile  oil  silk  or  similar  stuff 
before  inserting  the  looij  threads  and  pull  it,  folded,  clown  with  the 
graft,  as  recommended  by  Thilliez.^  Or  one  could  employ  the 
paraffined  lead  plate,  as  detailed  later.  If  a  one-piece  graft  is  not 
large  enough,  two  may  be  joined  together  and  handled  as  one,  or  one 
may  be  applied  to  the  globe,  the  other  to  the  lid  and  their  lower 
edges  stitched  to  the  tissue  at  the  bottom  of  the  newly-made  pocket. 
Where  the  rest  of  the  bulbar  conjunctiva  is  fairly  normal,  one  may, 
as  advised  by  de  Wecker,  combine  the  transplanting  of  Teale  or 
Knapp  (p.  332)  with  the  mucous  grafting. 

2.  Pedunculated  skin  flaps,  under  existing  conditions,  probably 
offer  a  greater  measure  of  success  than  do  mucous  grafts,  for  the 
cure  of  total  symblepharon,  yet  these,  too,  are  far  from  reliable. 
A  pioneer  in  their  use  for  this  purpose  was  Taylor.-  He  took  the 
flap  from  the  lower  lid,  in  a  case  of  downward  symblepharon,  with 
its  base  toward  the  nose.  After  loosening  it  up,  he  cut  a  vertical 
slit  through  muscle,  fascia  and  conjunctiva,  near  the  pedicle  of  the 
flap,  pushed  the  latter  through,  twisted  it  180°  on  its  long  axis,  and 
stitched  it  to  the  inner  side  of  the  lid  with  its  epidermis  next  to  the 
globe.  The  outer  defect  was  then  closed  by  sutures.  Chisolm^ 
made  the  same  operation,  except  that  the  pedicle  was  left  at  the  tem- 
poral side. 

Harlan^  for  a  case  of  total  lower  symblepharon,  formed  a  bridge 
flap  (with  relatively  narrow  pedicle  at  either  end)  on  the  cheek 
below  the  lid,  cut  through  into  the  bottom  of  the  newly  prepared 
fornix  along  the  upper  edge  of  the  flap,  pushed  the  latter  through 
the  opening,  twisted  the  pedicles  to  bring  what  had  been  the  lower 
edge  on  a  level  with  the  free  border,  and  stitched  it  in  phce  with  its 
epithelium  facing  the  eyeball.     The  result  was  only  a  partial  success. 

Panas^  in  a  similar  case  cut  a  flap  from  the  temple  and  one  from 
the  cheek,  carried  them  through  a  buttonhole  in  the  outer  orbito- 
palpebral  furrow,  applying  one  to  the  lid  and  the  other  to  the  globe, 
their  cuticular  surfaces  in  contact.  After  they  had  become  firmly 
adherent,  their  pedicles  were  cut  and  the  buttonhole  closed.  For 
total  symblepharon  of  both  lids,  the  same  surgeon  took  a  large  flap, 
the  shajje  of  a  tennis  racket,  from  the  temple,  pedicle  near  the  orbit, 

'  Jour,  des  Sc.  med.  de  Lille,  1898,  p.  143. 
-  Med.  Times  and  Gaz.,  i,  July,  1876,  p.  4. 
^  Virginia  Med.  Monthly,  1877,  p.  180. 
■*  Trans.  Am.  rj])h.  Society,  iSgo. 
5  Mai.  des  Ycux,  T.  ii,  p.  182. 


CUTANEOUS    GRAFTS  337 

turned  it  in  through  the  palpebral  fissure,  and  put  the  raw  side  in 
apposition  with  the  two  freshly  dissected  tarsi.  At  the  end  of  three 
months  the  flap  was  bisected  horizontally,  to  reestablish  the  open- 
ing between  the  lids.  The  operation  was  undertaken  to  enable  the 
patient  to  wear  an  artificial  eye,  the  cornea  having  been  destroyed 
by  sulphuric  acid,  but  the  object  was  not  attained. 

In  a  case  of  double  total  symblepharon,  in  which  heteroplastic 
and  other  autoplastic  procedures  had  been  tried  in  vain,  Samelsohn^ 
succeeded  in  the  manner  following:  from  the  skin  of  one  lid  he 
borrowed  a  quadrilateral  flap,  which  was  left  attached  along  the 
ciliary  border,  and  turned  it  into  the  palpebral  fissure  to  line  the 
posterior  surface  of  the  opposite  lid.  Union  having  been  established, 
the  flap  was  severed  at  its  base  and  the  measure  was  repeated, 
from  the  other  side,  for  the  fellow  lid.  The  principal  cause  of 
failure  in  most  of  these  flap  operations  has  doubtless  been  neglect 
to  construct  a  capacious  artificial  cul-de-sac  and  to  provide  means 
for  its  preservation.  Panas,  with  his  two  flaps  for  the  restoration 
of  the  lower  fornix,  fulfilled  the  first  condition,  but  not  the  second. 
To  cover  only  one  side  of  the  raw  pocket  made  by  separating  the  lid 
is  clearly  a  lame  procedure. 

The  most  formidable  foe  to  be  combated  in  this  surgery,  is  the 
progressive  ankylosis  between  lid  and  globe,  which  tends  to  efface 
one's  work.  As  a  support  for  the  transplanted  tissue — to  keep  it  in 
place — in  coaptation  with  the  surface  it  is  to  unite  with,  and  to 
mold  the  cul-de-sacs — glass  or  porcelain  eye  shells  have  long  been 
employed.  The  trustiest  weapon  for  the  purpose  would  seem  to  be 
a  properly  fashioned  plate  of  soft  metal,  as  described,  along  with 
other  means  to  the  same  end,  in  the  next  section. 

With  a  view  to  the  prevention  of  a  rela])sc,  Scott-  everted  the 
lid,  put  it  on  the  stretch,  and  fixed  its  free  border  to  the  skin  with 
the  aid  of  fine  silver  sutures,  keeping  the  eye  occluded  until  the 
transplanted  tissue  took. 

3.  Cutaneous  Grafts. — The  transplantation  of  skin  by  the 
Le  Fort- Wolfe  method,  to  replace  lost  substance  in  the  surgical  treat- 
ment of  sym.blepharon  has,  like  that  with  mucous  grafts,  proven  of 
little  value.  Their  great  thickness,  and  the  excessive  degeneration 
and  shrinkage  which  they  usually  undergo,  having  necessitated  their 
abandonment.     Of  late  years  their  use  has  been  confined  mainly  to 

^  Heidelberg  Congress  Report,  1892,  p.  149. 
-  Lancet,  Jul}'  31,  1897. 


338  OPERATIONS    UPON    THE    CONJUNCTIVA 

the  restoration  of  the  cul-de-sacs  in  cases  where  the  ,^lobe  was 
absent.  C.  H,  May/  of  New  York,  has  reported  the  successful 
"  transplantation  of  a  large  Wolff  (Wolfe)  graft,  forming  a  new  lining 
for  the  orbit  and  permitting  the  wearing  of  an  artificial  eye."  The 
graft  was  wrapped  around  a  porcelain  support  and  the  whole, 
placed  in  the  new-made  socket,  where  a  few  fine  sutures  united  the 
edges  of  the  piece  with  those  of  the  conjunctiva. 

Epidermic  grafts,  on  the  other  hand,  afford  the  best  known 
means  of  repair  for  the  defect  under  consideration.  They  were  used, 
to  a  limited  extent,  in  symblepharon  operations  by  v.  Arlt,  in  small 
patches  upon  a  granulating  surface,  after  the  manner  of  Reverdin. 
Later,  more  extensively  and  in  broader  pieces,  by  Eversbusch- 
and  many  others. 

Czermak^  gives  an  ingenious  procedure  for  total  symblepharon 
of  the  lower  lid,  founded  on  a  method  of  epidermization  by  Evers- 
busch.  The  palpebral  fissure  is  extended  to  the  outer  rim  of  the 
orbit  by  a  horizontal  incision  with  the  scalpel.  From  the  outer 
extremity  of  this  another  is  made,  down  and  in,  along  the  orbito- 
palpebral  furrow,  till  it  reaches  a  point  one  and  one-half  centimeters 
below  the  inner  canthus.  The  incision  is  deep  enough  to  include 
the  whole  thickness  of  the  lower  lid,  which  latter  is  dissected  up  in 
the  form  of  a  flap  with  its  pedicle  inward.  The  flap  or  lid  is  then 
turned  back  over  the  nose,  the  bleeding  is  stopped,  and  the  raw 
surface  of  the  globe  and  orbital  contents  covered  over  with  a  Thiersch 
graft.  The  entire  area  is  dusted  over  with  iodoform  powder  and 
covered  with  a  piece  of  tin-foil,  or  gutta-percha  tissue,  well  smeared 
on  both  sides  with  vaselin.  This  covering  must  extend  beyond  the 
outer  and  under  borders  of  the  wound  and  be  pushed  snugly  into 
the  angle  at  the  base  of  the  flap.  Above  it  must  overlap  the  cornea. 
If  the  latter  is  transparent,  gutta-percha  tissue  is  chosen  instead 
of  foil.  The  graft  is  made  to  cover  the  lower  half  of  the  cornea  also. 
Now  another  epidermis  graft,  correspondingly  large,  is  laid  on 
the  tissue  (or  foil),  epithelium  downward,  and  the  flap  is  turned 
back  into  place.  Both  lids  are  now  covered  with  a  piece  of  gutta 
tissue  greased  witli  vaselin,  and,  ()\er  all,  the  regulation  coUon 
pad  and  roller  bandage.  The  foil  or  tissue  keeps  tlie  two  grafts 
apart  while  they  heal.     As  soon  as  they  have  l)ecome  firmly  adherent, 

'  Arch,  of  Oph.,  vol.  xxx,  No.  5,   igoi. 

2  Miinch.  med.  Wochschr.,  1887,  Nr.  i  u.  2. 

'Aug.  Operatioiu'n,   1803,1).  ,i°''- 


TIIIERSC'ir    GRAFTS  339 

with  confi.miralion  like  thai  of  llic  llap.  an  incision  is  mack-  alon,-^ 
the  margin  of  the  ])o>UTior  (Icfi-cl.  that  nuisl  run  cxaclly  as  (\U\  the 
one  by  which  the  llap  was  originally  outHncd.  Jn  this  way  a  cut  is 
made  thai,  by  the  contraction  of  the  surrounding  tissue,  is  seen 
slightly  to  gape.  Then  the  whole  convex  edge  of  the  llaj)  and  that 
part  of  the  upper  edge  near  the  point,  made  by  the  first  or  horizontal 
cut,  is  freshened  with  the  scissors  and  sutured  lo  the  surrounding 
skin.  'J'luis  is  formed  a  deep  culde-sac.  A  linear  scar  remains, 
of  course,  and  the  lower  lid  looks  i)uffy,  "but  faults  like  these," 
says  Czermak,  "are  not  to  be  taken  into  account  in  such  desperate 
cases."  He  considers  the  operation  of  special  utiliiy  in  making  a 
new  socket  for  holding  a  glass  eye. 

But  it  is  in  the  United  States  that  the  em])l()yment  of  epidermic 
grafts  in  this  connection  has  been  attended  with  the  highest  degree 
of  definite  success.  Hotz^  advocated  the  use  of  Thiersch  grafts  to 
replace  the  destruction  of  conjunctiva  in  extensive  symblej^haron. 
Among  the  first  signal  triumphs  in  this  country  was  one  at  the 
hands  of  C.  H.  May-  (in  May,  1897)  of  New  York.  There  was  total 
symblepharon  of  both  lids.  A  number  of  large  epidermic  grafts 
were  used  which  were  kept  in  place  by  a  porcelain  shell  resembling 
an  artilicial  eye.  The  result  was  perfect.  Four  years  after  the 
operation  it  was  still  so.  In  April,  1899,  the  same  surgeon,''  after 
vain  attempts  to  relieve  an  extensive  lower  symblepharon  by  older 
methods,  detached  it  freely  and  placed  a  large  Thiersch  graft  over 
the  defect  thus  made.  This,  too,  was  kept  in  place  by  means  of 
the  porcelain  shell.  The  cornea  was  transparent  over  two-thirds 
of  its  area,  yet  the  shell  was  well  tolerated.  In  addition,  the  graft 
was  stitched  to  the  margins  of  the  raw  surfaces  l)y  delicate  sutures. 
The  graft  adhered  promptly  and  the  symblepharon  was  cured. 
Fifteen  months  afterward  the  effect  of  the  operation  had  nol  dimin- 
ished. In  July  and  August,  1899,  by  two  successive  operations, 
Hotz^  relieved  a  nearly  complete  symblepharon  of  the  upper  lid, 
covering  the  raw  surfaces,  after  dissection,  with  broad  Thiersch  grafts. 
Knowing  of  ]May's  use  of  the  porcelain  shell  to  hold  the  graft  in 
place  and  having  no  such  shells  at  his  disposal,  he  "cut  from  a  ihin 
sheet  of  lead  an  oval  disk  large  enough  that  when  slij^ped  under  the 
lids  it  would  till  the  whole  space  from  the  retrotarsal  sulcus  of  the 

1  Annals  of  Oph.,  April,  1893. 

2  Reported  in  the  Archives  of  Oph.,  April,  1899. 

'  Reported  in  Arch,  of  Oph.,  vol.  xxx.  No.  5,  1901. 
■•Oph.  Record,  Nov.,  1899. 


340  OPERATIONS  UPON  THE  CONJUNCTWA 

upper  lid  to  that  of  the  lower  lid,  and  shaped  and  molded  it  so  as  to 
fit  accurately  the  curvature  of  the  ball.  A  Thiersch  graft,  taken 
from  the  arm,  was  spread  out  smoothly  over  the  plate,  epidermis 
toward  the  lead,  in  such  a  manner  that  it  covered  the  upper  two- 
thirds  of  both  sides  of  the  plate.  Thus  mounted,  the  plate  was 
inserted  under  the  lids  as  we  insert  an  artificial  eye.  The  lid  borders 
were  united  by  three  sutures."  The  eye  was  dressed,  and  lid  sutures 
removed  on  the  fourth  day.  Although  the  graft  was  adherent 
throughout,  the  plate  was  worn  four  days  longer. 

The  second  operation  was  for  the  purpose  of  piecing  out  with  a 
Thiersch  graft  a  small  area  that  the  first  one  failed  to  cover.  The 
eye  was  sightless  and  the  operation  was  to  make  a  prothesis  practi- 
cable. Dr.  Hotz  has  just  informed  me  that  the  patient  is  wearing 
the  glass  eye  wiih  perfect  comfort  at  the  present  time  (March,  1906). 
In  November,  1901,  Hotz^  presented  at  a  meeting  of  the  Chicago 
Medical  Society  a  case  wherein  he  had  cured  almost  total  lower 
symblepharon  in  a  similar  manner.  Instead  of  the  large  plate, 
filling  the  entire  conjunctival  sac,  as  in  the  first  case,  he  used  one  the 
size  and  shape  of  the  inner  aspect  of  the  lower  lid,  with  four  small 
holes  through  it  near  the  upper  edge.  The  plate  was  covered  with 
the  graft,  put  into  the  new  cul-de-sac  and  fastened  along  the  free 
border  by  silk  sutures  passed  through  the  perforations  and  through 
the  lid.  Two  supplementary  operations  were  required  to  complete 
the  cure  in  both  of  these;  the  lead  plate  also  was  used,  but  the  sutur- 
ing together  of  the  lids  was  omitted.  Fifteen  months  after  the 
first  operation  and  three  after  the  last  the  lid  was  free,  easily 
evertible,  and  there  was  perfect  motility  of  the  eyeball.  In  this  case, 
the  greater  part  of  the  cornea  was  transparent — had  escaped  in- 
jury— and  the  sight  was  preserved. 

At  a  meeting  of  the  Ophthalmic  Section  of  the  Philadelphia 
Medical  Society,  April  17,  1900,  Oliver  reported  a  case  of  complete 
restoration  of  the  conjunctival  sac  by  a  single  epidermic  graft. 
Indeed,  since  the  publication  of  Hotz's  and  May's  first  articles  on 
the  subject  such  operations  have  been  made  by  ophthalmic  surgeons 
all  over  the  land  and,  in  numerous  instances,  with  most  gratifying 
results.  A  notable  series  of  six  cases  was  reported  and  exhibited 
by  H.  W.  Woodruff-  at  the  meeting  of  the  Chicago  Ophthalmologic 
Society,  February  10,  1903.     Three  had  been  relieved  of  high-grade 

Med.  Recorder,  Dec.,  iqoi. 


1  Chicago  Med.  Recorder,  Dec 
-  Annals  of  Oph.,  .MarclT,  190,: 


WOODRUFFS    MKTHOl)  341 

or  total  symblepharon  and  three,  where  the  globe  had  been  enu- 
cleated and  the  cul-de-sacs  had  been  effaced,  were  furnished  with 
new  sockets.     Woodruff  thus  describes  his  mode  of  procedure: 

"The  patient  should  be  under  a  general  anesthetic,  preferably 
chloroform.  The  eyebrow  and  skin  about  the  eye,  and  the  surface 
from  which  the  graft  is  to  be  taken  should  have  been  previously 
thoroughly  cleansed  with  green  soap  and  hot  water,  washed  with 
alcohol,  and  bandaged.  Immediately  before  the  operation  is  begun 
the  field  is  freely  flushed  with  boric  acid  solution.  If  a  pscudopteryg- 
ium  is  present,  it  is  first  dissected  from  the  cornea,  and  the  lid  is 
thoroughly  freed  from  its  attachment  to  the  eyeball,  and  the  cul- 
de-sac  must  be  made  large  in  all  dimensions.  Cicatricial  bands 
should  be  removed  entirely.  Bleeding  is  checked  by  hot  water. 
A  plate  is  now  cut  from  a  sheet  of  block  tin,  which  will  snugly  fit 
into  the  new-formed  cul-de  sac.  The  corners  are  rounded  off  and 
the  edges  smoothed  with  the  scissors  or  file.  If  the  case  be  one  of 
symblepharon,  and  there  is  danger  of  the  plates  rubbing  on  the 
cornea,  it  may  be  cut  out  in  the  center  to  the  extent  required.  Four 
holes  are  made  for  the  sutures,  two  at  the  outer  and  two  at  the 
inner  angle  of  the  plate,  to  correspond  to  the  lid  margin.  A  razor 
which  is  known  to  be  in  good  condition  is  used  for  removing  a  thin 
layer  of  skin,  about  one-third  wider  and  more  than  three  times  as 
long  as  the  plate.  In  the  method  known  as  Thiersch's  the  trans- 
planted flap  includes  only  the  epidermis  and  superficial  layer  of 
the  dermis.  The  graft  is  best  taken  from  the  inner  surface  of  the 
arm,  which  is  put  on  the  stretch  by  firm  pressure  with  the  hand,  and 
made  flat  by  pressure  with  the  razor  while  cutting.  The  graft  is 
transferred  at  once  to  the  plate,  and  folded  over  it  with  the  raw 
surfaces  external.  Plate  and  graft  are  then  pushed  into  the  cul  de- 
sac,  and  sutured  to  the  lid  near  its  margin,  tying  them  over  small 
rolls  of  gauze.  The  lids  may  be  sewed  together  and  dressed  with 
gauze,  and  bandaged  in  the  usual  way.  Both  eyes  should  be 
bandaged  as  long  as  the  plate  is  in  place,  and  absolute  quiet  main- 
tained. The  plate  is  removed  in  four  days,  and  more  freedom 
allowed  the  patient." 

This  is  essentially  the  method  as  generally  employed  in  America. 
It  will  be  observed  that  Woodruff  speaks  of  having  used  plates  of 
block  tin.  This  is  probably  a  cleaner  metal  for  the  purpose  than  is 
lead,  less  affected  by  the  secretions  of  the  eye  and  the  fluids  in  the 
raw  tissues,  though  in  other  respects  there  is  no  choice  between 


342  OPERATIONS  UPON  THE  CONJUNCTIVA 

them.     Woodruff  continues,  "The  particular  advantages  claimed 
for  the  use  of  the  plate  over  any  other  method  of  skin  grafting  are: 

"  I.  It  enables  one  to  place  the  graft  at  once  in  the  position  wanted. 

"  2.  It  holds  it  down  in  the  very  bottom  of  the  artificial  cul-de-sac 
until  it  has  adhered,  so  that  the  raw  surfaces  of  the  lid  and  ball  in 
no  part  can  again  unite  with  each  other  in  this  angle,  and,  even 
when  the  graft  Hves,  gradually  push  it  upward,  as,  in  my  experience, 
it  does,  unless  the  plate  is  used. 

"3.  We  secure,  with  the  plate,  accurate  approximation  over  the 
whole  extent  of  the  graft,  and  rest." 

Weeks,  of  New  York,  at  the  Congress  of  Ophthalmology,  Lucerne, 
1904,  gave  a  method  for  the  restoration  of  the  conjunctival  cul-de- 
sacs  that  he  declared  to  have  been  highly  successful  in  cases  of 
anophthalmos  with  obliteration  of  the  socket.  He  believed  that  the 
procedure  owed  its  efficacy  solely  to  the  fact  that  a  fixed  point  of 
attachment  was  found  for  the  graft  in  the  periosteum  at  the  rim 
of  the  orbit.  In  addition,  however,  he  had  made  use  of  a  plate 
for  the  support  of  the  transplant.  In  this  instance  the  plate  is 
gutta-percha,  such  as  is  employed  by  the  dentists  under  the  name 
of  "base-plate."  A  piece  of  this  is  cut  to  the  desired  outline, 
molded  to  shape  after  immersion  in  hot  water,  and  its  form  definitely 
fixed  by  putting  it  in  cold  water.  The  first  step  of  the  method 
is  the  making  of  a  free  canthotomy,  in  order  to  obtain  room  to 
operate.  Only  one  fornix  is  restored  at  a  time.  The  lid  is  detached 
almost  to  the  margin  of  the  orbit,  and  the  cavity  packed  with  cotton 
wet  with  normal  salt  solution.  A  Wolfe  graft  is  rapidly  cut  from 
the  arm,  freed  from  subcutaneous  tissue  and  dipped  in  the  warm 
salt  water.  It  is  then  folded,  epithelium  inward,  and  three  double- 
armed  sutures  passed  through  at  the  bottom  of  the  crease,  leaving 
loops,  two  millimeters  long,  on  the  cutaneous  surface.  The  sutures 
are  next  put  through  the  periosteum  of  the  orbital  rim,  from  the 
bottom  of  the  newly  formed  cul-de-sacs,  and  out  on  the  cheek.  The 
graft  is  helped  into  place  while  the  sutures  are  all  drawn  down, 
and  threads  are  tied  over  rolls  of  iodoform  gauze.  Small  interrupted 
sutures  fasten  the  graft  to  the  conjunctiva  of  the  lid  and  to  that 
of  the  ocular  stump.  Now  the  plate  is  inserted  and,  lastly,  the 
stitches  put  in  to  close  the  canthotomy.  The  deep  sutures  are  left 
in  for  ten  to  fourteen  days,  those  in  the  conjunctiva  are  removed 
in  one  week.  The  i)late  is  left  in  situ  until  all  shrinkage  ceases 
in  the  fiap. 


RESTORATION    OJ'    (  TL-DK-SACS  343 

'JI1C  writer,  havinij;  found  the  ,<j;ulla-percha  i)lale  unsatisfaclory, 
went  back  to  the  lead.  Willi  it  tiic  ])criosteal  sutures  arc  a  supcr- 
lluous  complication.  A  valuable  expedient  is  that  of  Wilder,  of 
Chicago,  whereby  the  leaden  shell  is  coated  with  paraffin.  By 
holding  the  ])late  with  forceps  by  its  middle,  and  dipping  it  several 
times  in  liquid  ])arairm  of  high  melting-point,  the  surface  and  edges 
are  made  absolutely  smooth  and  non-irritating.  Another  good 
suggestion  of  Wildcr's  is  that,  instead  of  making  a  number  of  small 
holes  in  the  phite  for  the  passage  of  the  sutures,  two  large  openings 
are  made,  one  on  either  side  of  the  center.  These  serve  just  as  well 
for  the  threads,  besides  affording  much-needed  facilities  for  drainage 
and  cleansing.  The  tip  of  an  eye-dropper  can  l)e  inserted  at  one 
opening  and  the  injected  fiuid  escape  at  the  other.  Jn  conjunction 
with  a  Thiersch  graft  suturing  to  the  conjunctiva  is  unnecessary. 
Though  it  is  wise  to  fix  the  graft  to  the  plate  by  a  few  turns  of 
thread  in  order  to  prevent  it  from  slipping  while  being  put  into  the 
socket. 

Upper,  outer,  and  lower  cul-de-sacs  can  all  be  restored  by  a  single 
operation.  Indeed,  there  is  every  good  reason  for  doing  whatever 
is  needed  all  at  one  sitting,  and  none  against  it.  If  need  be,  the 
entire  plate  may  be  covered  by  the  graft.  In  any  case  it  is  better 
to  have  a  superfluity  than  a  lack  of  tissue  on  the  metal. 

Since  writing  most  of  the  foregoing  I  have  had  the  good  fortune 
to  restore  perfectly  the  cul-de-sacs  in  a  few  cases  of  total  symble- 
pharon  where  the  eye  was  present,  and  to  make  artificial  sockets 
that  are  entirely  practical  and  satisfactory  for  the  w'earing  of  a 
I)rothesis  in  a  number  of  others  where  enucleation  had  been  ])er- 
formed  and  there  had  been  complete  obliteration  of  the  conjunctival 
sac.  In  the  first  category  the  lead  or  block-tin  plate,  with  and  with- 
out the  paraffin  coating,  has  been  employed,  and  w-ith  and  without 
the  opening  for  the  cornea.  In  the  second  class,  i.e.,  those  in  which 
the  bulbus  had  been  removed,  plates  of  the  same  materials  have 
been  used  w^ith  or  without  perforations  for  drainage  and  cleansing. 
Of  the  tw^o  metals,  lead  or  block-tin,  for  the  plate  I  prefer  the  last 
as  being  least  affected  by  the  fluids  normally  or  artificially  present 
in  the  eye.  The  great  advantages  of  such  plates  are  that  they  can 
be  readily  fashioned  of  any  shape  and  size  by  means  of  the  fingers 
and  strong  scissors,  and  perforations  of  suitable  dimensions  are 
easily  made  in  them.  Moreover,  they  can  be  bent  by  the  fingers 
into  forms  similar  to  that  of  an  ordinarv  artificial  eve.     In  order, 


344  OPERATIONS  UPON  THE  CONJUNCTIVA 

however,  to  make  them  evenly  concavo-convex  so  that  there  will 
be  no  signs  of  crimping  or  ruffling  around  the  edges,  a  more  elaborate 
handling  would  be  necessary.  Fortunately,  precision  so  great 
is  not  required.  When  it  is  to  be  fitted  over  the  eyeball  the  thick- 
ness of  the  plate  need  not  exceed  one  thrity-second  of  an  inch, 
especially  if  the  paraffin  coating  is  put  on.  But  when  the  newly 
formed  cul-de-sac  is  intended  for  receiving  and  holding  a  prothesis, 
particularly  one  of  the  Snellen  kind,  or  "reform  eye,"  it  should  not 
only  be  deep  and  long,  but  extra  wide  as  well,  so  that,  in  the  process 
of  cicatrization,  it  will  still  remain  of  fair  capacity.  Here,  then, 
a  thickness  nearer  one  sixteenth  of  an  inch  were  better.  This, 
heavily  coated  with  paraffin,  will  make  a  plate  that  very  closely 
resembles  a  glass  eye — especially  at  and  near  the  outer  border. 
In  lieu  of  a  sheet  of  metal  of  suflicient  thickness  I  have  fastened  two 
pieces  together  with  collodion.  At  least  one  perforation  in  the  plate 
may  be  regarded  as  an  absolute  necessity.  If  the  globe  be  intact,  a 
large  opening  corresponding  in  size  to  that  of  the  cornea  serves  to 
obviate  undue  pressure  and  friction  upon  this  sensitive  membrane. 
It  also  permits  of  inspection,  so  that  one  may  be  informed  as  to  the 
health  of  the  cornea  and  as  to  whether  or  not  the  posterior  leaf 
of  the  graft  is  "taking"  within  the  limbus.  Besides  it  gives  oppor- 
tunity for  irrigation.  Where  the  eye  is  absent  there  may  be  one 
or  two  perforations.  Should  the  graft  required  be  large  enough  to 
cover  the  entire  plate,  as  is  true  in  operations  for  restoration 
of  all  four  cul-de-sacs,  there  is  only  room  for  one  opening  3/16  to 
1/4  inch  in  diameter  in  the  center;  or  for  two,  each  about  1/8  inch, 
placed  close  together  on  the  horizontal  axis  of  the  plate.  Either 
will  serve  for  cleansing  the  cavity  or  for  manipulating  the  plate. 
If  the  openings  are  larger  they  deprive  the  graft  of  the  support 
it  needs.  A  squint-hook,  put  in  through  one  of  these  perforations, 
acts  well  as  a  handle  by  which  the  plate  may  be  mobilized  and 
withdrawn  when  the  proper  time  arrives.  In  coating  a  one-hole 
plate  with  paraffin  a  pair  of  fixation  forceps  may  be  thrust  through 
the  opening,  when  the  "spread"  of  the  instrument  will  sulfice  to 
hold  the  plate.  If  there  are  two  holes  one  |)rong  of  tlie  forceps 
is  passed  through  each. 

Apropos  of  the  paraflin  coating,  it  would  seem  to  be  of  unques- 
tionable value.  As  Wilder  has  pointed  out,  the  advantages  of  a 
plate  so  prepared  over  the  naked  metal  are  greater  smoothness, 
less   harshness,    and   the   very   desira])le   (pialilics,    in    a<l(lition,   of 


PTERYGIUM  345 

causing  the  epithelial  surface  of  the  graft  to  lie  evenly  spread  out, 
or  clinging,  and  the  facility  with  which  it  may  be  built  up  into 
appropriate  form  and  thickness.  Wilder  says  that  the  melting- 
point  of  the  paraflin  should  not  be  lower  than  130°  F.  I  would 
recommend  that  it  be  as  high  as  it  is  possible  to  obtain  it;  for  I 
have  observed  that  there  is  a  tendency  of  the  surface  to  become 
hummocky  and  for  a  ridge  to  form  along  the  palpebral  fissure 
after  the  plate  has  been  in  the  eye  for  a  few  days.  The  harder  the 
substance,  of  course,  the  more  uniform  the  coating  would  remain 
under  the  influence  of  the  animal  heat  and  the  movement  of  the 
tissues.  That  the  new  cul-de-sacs  must  be  fashioned  and  main- 
tained on  a  generous  scale  cannot  be  too  strongly  insisted  upon. 
Extra  free  division  of  the  tissues  at  the  outer  canthus  is  the  first 
essential  step.  This  is  nicely  sutured  as  soon  as  the  plate  is  put 
in  place.  The  plate,  if  of  adequate  size,  will  be  too  large  in  some 
instances  to  be  removed  without  making  a  second  canthotomy, 
which  also  should  be  followed  immediately  by  suturing.  After 
this  a  somewhat  smaller  plate  may  be  substituted,  or,  if  the  original 
one  has  again  been  inserted,  it  may  be  cut  in  two  with  strong  scissors, 
in  situ,  before  removal. 

It  has  for  some  time  been  a  cherished  intention  on  the  part  of 
the  writer  to  procure  a  number  of  ordinary  shell  eyes  of  varying 
sizes,  and  to  have  made  in  them  suitable  openings.  These  are  to 
be  coated  with  the  paraffin  and  used  instead  of  the  lead  plates.  I 
fancy  they  would  possess  distinct  advantages  over  the  metal  plates 
in  all  save  the  doubtful  one  of  allowing  themselves  to  be  cut  in  two 
while  in  position. 

More  recently  we  have  taken  the  graft  directly  from  the  razor 
and  placed  it  on  the  plate,  i.e.,  without  dipping  it  in  the  salt  solution; 
nor  have  any  sutures  been  employed  in  holding  the  graft  to  the 
plate. 

PTKRV(]IUM. 

Pterygium,  also  called  pterygion,  is  from  the  Greek,  meaning, 
literally,  little  wing,  and  in  German  it  is  Flugelfell,  or  wing  film. 
The  term  is  used  in  the  various  branches  of  zoology  to  denote 
certain  fins  of  fishes,  feathers  of  birds,  and  coverplates  of  insects. 
In  pathological  anatomy  the  word,  besides  its  more  common  applica- 
tion here  under  discussion,  is  also  employed  with  reference  to  a 
growth    of   skin   over   the   nails.     Indeed,    ocular    j)terygium    was. 


346  OPERATIONS    UPON    THE    CONJUNCTIVA 

by  Celsus,  called  unguis.  As  applied  to  the  eye,  the  word  signifies 
a  growth  of  thickened  or  otherwise  changed  conjunctiva  encroaching 
more  or  less  upon  the  cornea.  Two  varieties  are  recognized,  viz., 
the  true  and  the  false. 

True  pterygium  is  always  situated  in  the  horizontal  meridian  of 
the  eye  and  is  usually  the  result  of  prolonged  irritation  of  that 
part  of  the  conjunctiva  exposed  through  the  palpebral  fissure,  by 
wind,  dust,  etc.,  hence  rarely  occurring  in  females.  It  appears  as 
a  triangular  band  of  more  or  less  reddened  conjunctiva  with  its 
apex  primarily  at  the  limbus,  and  may  be  either  stationary  or 
progressive.  It  is  most  often  situated  on  the  nasal  side  of  the 
cornea  (internal  pterygium),  less  often  on  the  temporal  (external 
pterygium)  and  still  less  often  on  both  sides  at  once  (double  pteryg- 
ium). Its  rounded,  whitish  apex  is  usually  referred  to  as  the  head, 
the  adjoining  portion  as  the  neck,  and  its  wide,  fan-like  expansion 
as  the  body. 

Another  classification  is  made  of  true  pterygium  into  progressive 
and  stationary.  The  former  being  characterized  by  greater  vascu- 
larity, redness,  and  thickness  (pterygium  crassum),  while  the  latter 
is  pale  and  thin  (pterygium  tenuis).  Originally,  of  course,  the 
second  form  has  been  of  the  progressive  kind  which  has  become 
retrogressive. 

Progressive  pterygia  demand  operative  interference  at  the  earliest 
possible  moment,  in  order  to  insure  good  and  lasting  results.  In 
proportion  as  they  are  allowed  to  occupy  the  pupillary  area  of  the 
cornea,  the  sight  is  prejudiced,  both  immediately  and  consecutively. 

The  stationary  variety,  especially  when  the  cornea  is  but  slightly 
implicated,  may  be  safely  let  alone.  It  is  eminently  justifiable,  how- 
ever, that  they  be  removed,  if  only  for  cosmetic  reasons. 

The  number  of  operative  procedures  that  have  been  devised  for 
the  cure  of  the  growth  in  question  is  very  large,  but  for  convenience, 
the  methods  may  be  reduced  to  three  or,  at  most,  four. 

1.  Ablation,  or  the  complete  taking  away  by  excision,  or  by  the 
latter  combined  with  scraping  and  cauterization,  called  also  abscis- 
sion. 

2.  Transplantation — called  by  some  deviation,  and  ])y  others 
burying. 

3.  Ligation. 

4.  Cauterization  (Ihougli  hardly  admissible  except  as  an  ad- 
junct to  one  of  the  other  measures). 


PTERYGIUM  .:547 

I,  Operations  for  pterygium  were  resorted  to  in  \ery  early  times. 
The  growth  was  looked  upon  as  a  species  ol  tumor,  of  u  certain 
mahgnance,  and  it  was  dealt  with  by  ablation,  jjartial  or  comj^lete. 
Celsus/  for  example,  seized  the  neck  with  a  sharp  hook  and  passed 
through  it  a  thread,  to  which  he  held  with  one  hand  while,  by  means 
of  a  small  knife,  he  detached  the  neck  and  body,  severed  the  base, 
and  allowed  the  wound  to  heal  by  granulation.  If  at  the  nasal 
side,  he  was  careful  to  spare  the  caruncle,  as  to  remo\e  this  body, 
he  believed,  would  cause  epiphora. 

.Etius  and  Paulus,-  of  ^^gina,  also  made  ablation  of  the  pterygium, 
but  instead  of  using  a  knife,  they  detached  it  from  base  to  apex,  with 
the  aid  of  a  horsehair  passed  beneath,  which  they  worked  like  a  saw. 
According  to  Richter,^  however,  these  surgeons  left  the  head  be- 
hind, and  Acrel  was  the  first  to  dissect  off  this  part.  Richter 
himself  and  Scarpa,^  extirpated  the  corneal  portion  only.  The 
idea  of  closing  the  defect  left  after  ablation  of  the  pterygium 
first  occurred  to  Coccius.^  Previously,  the  diverging  lines  of 
the  pterygium  were  followed  in  the  extirpation,  a  large  trap- 
ezoid scleral  defect  was  left  to  heal  as  best  it  might,  in  con- 
sequence of  which,  not  only  did  there  remain  a  large  area  of 
cicatricial  tissue,  which  interfered  with  the  action  of  the  underlying 
rectus  muscle,  but  was,  moreover,  unseemly  in  appearance,  and 
often  leading,  through  overgrowth  of  granulation  tissue,  to  what 
was  called  "secondary  pterygium." 

To  obviate  this,  v.  Arlt''  in  cases  of  large  pterygia,  instead  of 
following  the  borders  of  the  scleral  portion,  made  two  converging 
incisions  which,  meeting  at  or  near  the  caruncle,  left  only  a  relatively 
narrow,  triangular,  scleral  wound  opening.  The  piece  excised, 
or,  if  you  will,  the  whole  bared  space,  was  manifestly  of  rhomboid 
or  diamond  shape,  its  greatest  measurement  being  horizontal. 
Later,  following  Coccius,  he  undermined  the  edges  and  brought 
them  together  by  fine  sutures.  When  the  growth  was  of  small 
dimensions  Arlt  often  contented  himself  by  merely  dissecting  off 
little  more  than  the  corneal  part,  leaving  the  scleral  division,  in 
front  of  which  he  sutured  together  the  conjunctiva,  to  disappear 
spontaneously. 

1  Rome,  A.  D.  i. 

2  Greece,  A.  D.  7. 

3  Treatise  on  Surgery,  Gottingen,  1771,  p.  92. 
^  Trait,  des  malad.  des  yeux,  1802-1S16. 

*  Ruete,  Lehrb.  der  Augenh.,  1854,  Bd.  ii,  S.  267. 

6  Die  Krankheiten  des  Auges,    i,  S.  164.     Prag.,  1S50. 


348  OPERATIONS   UPON   THE    CONJUNCTIVA 

If  the  abandoned  growth  became  swollen,  or  if  it  in  any  way 
inconvenienced,  it  was  excised  by  a  simple  snip  of  the  scissors.  A. 
Pagenstecher,  of  Wiesbaden,  adopted  this  method.  Arlt's  method 
of  ablation,  but  slightly  modified,  still  constitutes  one  of  the  favorite 
and  most  effective  pterygium  operations,  when  the  growth  is  of 
moderate  size  and,  as  performed  by  the  author,  may  be  described 
as  follows: 

The  eye  is  cleansed  and  put  under  local  anesthesia.  The  lids 
are  held  apart  by  the  blepharostat.  The  entire  width  of  the  growth, 
about  at  the  junction  of  the  neck  and  body,  is  caught  up  by  strong 
mouse-tooth  forceps,  where  an  opening  is  made  through  beneath 
it  with  knife  or  scissors.  If  it  is  loosely  attached  to  the  cornea, 
one  may  now  avail  one's  self  of  the  admirable  method  of  divulsion 
invented  by  Prince,  of  Springfield,  111.  This  consists  in  passing  a 
Prince  divulsor  or  a  flat  strabismus  hook  or  other  similar  instru- 
ment through  the  opening  and  forcing  it  toward  the  apex  with  a 
series  of  short,  prying  motions,  as  a  river  of  staves  uses  his  frow.  In 
this  way  one  often  has  the  satisfaction  of  seeing  the  cornea  stripped 
absolutely  clean.  If  the  growth  is  too  firmly  adherent  to  yield 
readily  to  this  maneuver,  a  keen,  narrow  bistoury,  or  small  scalpel, 
is  used  to  free  it  from  its  bed,  or  its  dissection  may  be  still  further 
facilitated  by  completely  dividing  the  growth  at  this  point  and  then 
dissecting  it  loose,  after  the  method  of  Fromaget,  of  Bordeaux.  ^ 
It  is  worked  from  the  limbus  of  the  cornea  toward  the  center,  first 
loosening  the  lower  edge,  then  the  upper,  then  between  the  two, 
always  hugging  the  cornea. 

It  is  well  before  loosening  the  apex  to  finish  the  incisions  that  out- 
line the  diamond  to  be  excised,  as  they  can  then  be-  placed  with 
greater  precision.  These,  made  only  with  small,  straight,  blunt 
scissors,  extend,  divergent,  for  a  short  distance  from  the  limbus, 
governed  by  the  size  of  the  pterygium,  then  convergent  to  meet  at 
or  near  the  caruncle  or  the  neighboring  canthus  (Fig.  220). 

We  may  now  try  to  rive  off  the  head  or  lip  by  prying.  If  this 
fails,  the  knife  is  passed  entirely  beneath  and  this  portion  is  severed 
by  a  light  sawing  movement.  To  begin  the  dissection  at  the  head, 
except  in  the  event  of  the  pterygium  being  a  cicatricial  or  an  un- 
usually meaty  one,  is  unsurgical.  Finally  the  excision  of  the 
scleral  part  is  finished  with  the  scissors,  taking  care  to  avoid  the 
sheath  and  tendon  of  the  rectus.     Any  corneal  remains  of  the  growth 

1  L'Ophthalniologie  Provinvialc,  Oct.,  191 1. 


PTERYGIUM 


349 


are  scraped  away  with  a  convex  scalpel,  or  sharp  curct,  and  the 
episcleral  tissue  in  the  immediate  vicinity  of  the  linil)us  is  like- 
wise got  rid  of.  To  prevent  overlapping  the  cornea,  two  vertical 
incisions  arc  now  made  in  the  conjunctiva,  one  upward  and  the 
other  downward,  for  a  few  millimeters  from  the  base  of  the  denuded 
space  on  the  cornea,  the  edges  of  the  conjunctival  wound  are  under- 
mined for  some  distance  by  means  of  the  blunt  scissors  and  brought 
lightly  together  by  very  fine  silk  sutures  (Fig.  221).  These  have 
been  recently  boiled  in  vaselin-paraflin.  One  should  see  to  it  that 
each  bite  of  the  thread  is  deep  enough  to  hold  firmly. 

A  carefully  applied  four-yard  wet  netting  roller  is  put  on,  the 
patient  is  told  to  keep  very  quiet  for  forty-eight  hours,  and  to  re- 
frain from  use  of  the  uncovered  eye,  also  to  keep  it  mostly  closed. 


At  the  end  of  this  time  occurs  the  first  inspection  and  redressing. 
After  this,  daily  for  a  few  times.  The  sutures  are  taken  out  three 
or  four  days  from  the  date  of  operation. 

Excision  with  Conjunctivoplasty. — Having  occasion  to  remove 
a  vascular  tumor  involving  the  sclero-corncal  junction,  it  occurred  to 
the  author  to  embody  in  the  operation  his  method  of  making  the 
conjunctival  flap  in  the  operation  of  trephination  of  the  sclera  (page 
648).  The  issue  was  fortunate  to  a  degree  that  impelled  him  to 
apply  the  same  principle  to  the  removal  of  pterygium.  Up  to  the 
moment  when  the  excision  of  the  growth  is  completed  one  proceeds 
precisely  as  in  fashioning  the  flap  referred  to  excepting  that  the  flrst 
two  incisions  of  the  conjunctiva  are  not  so  long.     There  is  the  same 


350 


OPERATIONS  UPON  THE  CONJUNCTIVA 


tunneling  through  with  the  scissors,  the  same  loosening  and  prying  up 
with  the  spatula,  and  the  same  shaving  of  the  cornea  with  the  curved 
blunt  bistoury  (Fig.  222).  The  last,  of  course,  includes  the  growth. 
The  flap  thus  formed  is  cut  squarely  off  6  to  8  mm.  from  the  limbus, 
and  its  stump  left  attached  to  the  globe,  i.e.,  not  undermined  (Fig. 
22  7^).  Two  othar  flaps  are  made,  as  per  the  dotted  lines,  their  free 
ends  at  the  defect  caused  by  the  excision  of  the  first  flap.  To  cover 
the  defect  the  extremities  of  these  two  flaps  are  brought  together  and 
fixed  by  a  single  suture,  which  is  placed  a  little  to  the  corneal  side  of 
the  middle  of  each  flap  (Fig.  224).     Lastly,  each  flap  is  united,  by  a 


23.  Fig.  224. 

-Beard's  method  for  pterygium  or  other  growth. 


suture,  to  that  portion  of  the  conjunctiva  from  which  the  original 
flap  was  severed.  Thus  the  conjunctiva  is  prevented  from  overlap- 
ping the  raw  area  of  the  cornea.  The  latter  heals  without  leaving  a 
scar.  The  method  is  suitable  for  small  tumors  and  for  both  true  and 
false  pterygia.  It  is  true  that,  as  applied  to  pterygium,  the  base  of 
the  growth  is  left  behind,  but  this  docs  not  matter.  The  apex  is  got 
rid  of,  and  normal  conjtinctixa  intervenes  between  the  l)ase  and  the 
corneal  defect. 

2.  Transplantation  of  pterygium,  in  order  to  divert  its  growth 
from  the  cornea,  was  originally  conceived  by  tlie  elder  Desmarres.^ 

1  Trait<-  theoriqiie  et  pratiqtie  des  maladies  des  ycux,  20  edition,    1855, 
Pari.s,  t.  ii,  p.   i68. 


PTERVGIUM 


351 


This  surt^con  dissccled  up  ihc  .yrowih  like  a  llaj),  from  ils  base  lo  its 
apex,  llien  from  a  convenient  point  on  the  lower  ed.t^e  of  the  con- 
junctival opening  he  carried  an  incision,  i)arallel  with  the  corneal 
margin,  sufriciently  far  to  accommodate  the  loosened  pterygium. 
Into  this,  after  liaving  been  ()i)ene(l  into  a  triangular  bared  space, 


Fig.  225. — Desmarre: 

he  turned  the  growth  and  secured  it  there  by  sutures  (Figs.  225 
and  226).  The  defect  remaining  about  the  limbus  was  left  to  heal 
by  granulation.  When  the  apex  of  the  pterygium  is  truncated  the 
younger  Desmarres^  advises  dividing  it  into  two  equal  portions  by  a 


horizontal  incision,  and  transplanting  the  two  halves  into  two  con- 
junctival notches,  one  above  and  the  other  below. 

Knapp,-  in  order  to  adapt  the  Desmarres  double  transplantation 
method  to  the  larger  pterygia,  modified  the  procedure  in  certain 
important  respects,  the  technic  of  which,  as  described  by  him  in 
Norris  and  Oliver's  System,  p.  836,  is  essentially  thus: 

1  Legons  cliniques  sur  la  chirurgie  oculaire,  Paris,  1S74,  ])aj;c  302. 

2  Arcliiv.    Ill-  ()i»litlialmologic,  Bd.  xiv,  I  Al>theil.,  iS68,  S.  2O7. 


35- 


OPERATIONS    UPON    THE    CONJUNCTIVA 


The  body  of  the  pterygium  is  seized  with  fixation  forceps  and 
detached  with  a  narrow  cataract  knife  from  near  the  hmbus  to  and 
including  apex,  boldly  cutting  through  the  epicorneal  tissue  so  as 
to  leave  nothing  of  the  growth  behind.  The  scleral  portion  is  in- 
cised along  its  upper  and  lower  borders  and  the  cuts  prolonged  in 
a  curved  direction  into  the  upper  and  lower  fornices.  The  whole 
is  then  loosened  from  the  eye  in  the  form  of  a  triangular  flap  which 
is  split  horizontally  into  two  equal  portions.  The  part  representing 
the  gray  infiltrated  head  is  cut  off.  The  tip  of  each  half  is  stitched 
into  the  corresponding  angle  formed  by  the  upward  and  dow^n- 
ward  prolongations  into  the  fornices.  To  cover  the  remaining 
defect,  two  vertical  incisions  are  made  in  the  conjunctiva,  beginning 
at  the  limbus,  extending  up  and  down  for  several  millimeters, 
getting  further  from  the  cornea  as  they  advance.     Thus  two  squarish 


I,':         ^ 


Fig.  227. — Desmarres,  jr.-Knapp. 


Fig.  228. — Desmarres,  jr.-Knapp. 


flaps  are  outlined  which  are  undermined  and  joined  together  by  two 
sutures.  The  better  to  fix  the  various  flaps  and  to  keep  them 
from  overriding  the  cornea,  the  suture  furthest  from  the  cornea  is 
made  to  include  the  conjunctiva  at  the  apex  of  the  angle  between  the 
two  halves  of  the  divided  pterygium  (Figs.  227  and  228;. 

Both  eyes  are  bandaged  for  twenty-four  hours — afterward  only 
the  operated  eye — though  the  patient  is  advised  to  use  the  uncovered 
eye  as  little  as  possible  the  flrst  week.     The  threads  arc  removed 


PTKRYC.IUM 


353 


in  five  or  six  days,     liolli  lliis  and  Dcsniarrcs'  arc  true  transi)lanta- 
tion  operations. 

]\IcReynolds,i  of  Dallas,  has,  by  a  most  ingenious  and  effective 
modification  of  the  original  Desmarres  operation,  given  new  im- 
petus to  the  transplantation  method  in  this  country.  The  present 
writer  is  among  the  many  who  can  testify,  from  experience  with  a 
number  of  cases,  to  the  excellence  of  the  procedure.  The  different 
steps  of  the  operation,  as  described  by  its  author,  are  as  follows: 

1.  Grasp  the  neck  with 
strong  narrow  forcejis. 

2.  Pass  a  Graefe  knife 
through  the  constriction  and 
as  close  as  possible  to  the 
globe;  then,  with  the  cutting 
edge  turned  toward  the  cornea, 
shave  the  growth  smoothly 
from  that  membrane. 

3.  With  the  fixation  forceps 
still  hold  the  pterygium  and 
with  slender  straight  scissors 
divide  the  conjunctiva  and 
the  subconjunctival  tissue 
along  the  lower  margin  of  the 
pterygium,  commencing  at  the 
neck  and  extending  to  the 
canthus,  a  distance  of  1/4  to 
1/2  inch. 

4.  Still  hold  the  pterygium 
with  the  forceps  and  separate 
the  body  of  the  growth  from 
the  sclera  with  any  small, 
non-cutting  instrument.  (A  Hat  (}raefe  strabismus  hook  serves 
admirably.) 

5.  Now  separate  well  from  the  sclera  the  conjunctiva  lying  be- 
lovv^  the  oblique  incision  made  with  the  scissors. 

6.  Take  black  silk  thread,  armed  at  each  end  with  smallest 
curved  needles  and  carry  both  of  these  needles  through  the  apex  of 
the  pterygium  from  within  outward.  Separate  one  from  the  other 
by  sufficient  amount  of  the  growth  to  secure  a  firm  hold  (Fig.  229). 

1  Journal  of  the  American  Medical  Association,  Aug.  9.  1902. 
23 


-McReynold's  modificalioii  of 
Desmarres',  Sr. 


354 


OPERATIONS  UPON  THE  CONJUNCTIVA 


7.  Then  carry  these  needles  downward  beneath  the  loosened 
conjunctiva  lying  below  the  oblicjue  incision  made  by  the  scissors. 
The  needles  after  passing  in  parallel  directions  beneath  the  loosened 
lower  segment  of  the  conjunctiva,  until  they  reach  the  region  of 
the  lower  fornix,  should  then  emerge  from  beneath  the  conjunctiva 

at  a  distance  of  about  1/8  to  1/4 
inch  from  each  other. 

8.  With  the  forceps  lift  up  the 
loosened  segment  of  conjunctiva 
and  gently  exert  traction  upon 
the  free  ends  of  thread,  which 
have  emerged  from  below,  and 
the  pterygium  will  glide  beneath 
the  loosened  lower  segment  of 
conjunctiva,  and  the  threads 
may  then  be  tightened  and  tied, 
while  the  surplus  portions  of 
thread  are  cut  off,  leaving  enough 
to  facilitate  the  removal  of  the 
threads  after  proper  union  has 
occurred  (Fig.  230).  It  is  very 
important  that  no  incision  be 
made  along  the  upper  border  of 
the  pterygium,  because  it  would 
gap  and  leave  a  denuded  space 
when  downward  traction  is  made 
upon  the  pterygium. 

If  the  head  of  the  pterygium 
is  very  large,  it  is  cut  off  before 
the    pterygium   is   drawn   down 
beneath  the  loosened  segment  of 
of  the  cornea  occurs,  McReynolds 
ply  trims  away  the  offending  portion  of  conjunctiva.     This  is 
more  a  burying  than  a  transplanting  of  the  pterygium. 

The  writer  would  urge,  as  a  precautionary  act  of  no  little  impor- 
tance, that  before  proceeding  to  draw  the  pterygium  down  into  the 
prepared  pocket,  the  blepharostat  (or  retractor)  be  renu)\-e(l. 
The  effect  of  this  instrument  is,  by  its  pushing  the  conjunctiva  up 
into  the  fornix,  to  greatly  limit  the  extent  to  which  that  membrane 
can  be  drawn  down.     This  is  ])articularly  necessary  in  cases  of 


Fig.  230. — McReynold's  modification 
of  Desmarres,  Sr. 


conjunctiva, 
sim 


If  any  overlapping 


PTERYGIUM 


355 


elderly  subjects  and  in  those  afflicted  with  chronic  intlammations 
of  the  conjunctiva,  and  whose  cul-de-sacs  are,  in  a  measure,  obliterated 
from  atrophy.  It  is  also  highly  advisable,  before  actually  putting 
the  growth  in  its  new  place  beneath  the  conjuncti\'a,  to  take  it  by 
its  head  with  the  forceps,  pull  it  down  and  note  and  mark  the  j)lace 
where  it  fits  best. 

The  younger  Desmarres,^ 
for  large  pterygia  with  trun- 
cated apices,  divided  them  in 
two  and  transplanted  similar 
to  Knapp,  but,  like  Desmarres 
the  elder,  he  left  the  scleral 
defect  uncovered. 

Galezowski,-  after  mobiliz- 
ing the  pterygium,  put  a 
double-armed  suture  through 
the  apex,  tucked  the  growth 
back  beneath  the  semilunar 
fold,  or  the  caruncle,  where  he 
brought  the  suture  out  and 
tied  it. 

3.  Ligation. — In  connec- 
tion with  the  surgery  of  ptery- 
gium, this  measure,  though 
still  occasionally  resorted  to, 
may  be  considered  obsolete. 
Its  origin   is   associated  with 

the  name  of  Szokalski.-''  This  o])erator  passed  two  curved  needles 
beneath  the  pterygium,  one  near  the  apex,  the  other  near  the  base, 
both  being  attached  to  the  same  thread  (Fig.  231).  The  thread 
was  then  cut  close  to  the  needles.  In  this  manner  three  ligatures 
were  made,  two  single  and  one  (the  middle)  double.  The  single 
ones  were  tightly  knotted.  The  third,  formed  by  the  loop  of  thread, 
served  to  detach  and  lift  u])  the  i)terygium.  At  the  last  this  thread 
was  made  into  a  slip-loop  around  the  pterygium  and  the  ends 
fastened  to  the  cheek  by  means  of  collodion.  After  a  few  days  the 
growth  perished  and  was  excised. 


P"iG.  231. — Szokalski's  ligature 


'■  Lemons  cliniques  sur  l;i  chirurgie  oculaire,  Paris,  1874,  p.  302. 

-  Maladies  des  ycux,  1S88. 

^  Roser  u.  Wundcrlich  Archiv.,  1845,  ^r.  2. 


356  OPERATIONS  UPON  THE  CONJUNCTIVA 

Von  Arlt,^  in  a  case  of  cicatricial  pterygium,  following  blenor- 
rheic  conjunctivitis,  cast  two  ligatures  around  it  and  allowed  them 
to  cut  through.     The  pterygium  soon  after  disappeared. 

4.  The  thermal  cautery  as  a  single  measure  for  the  removal  of 
ptervgium,  though  it  has  been,  to  a  limited  extent,  used  in  this 
capacilv,  is  not  especially  to  be  commended.  Its  only  place,  in 
this  connection,  would  seem  to  be  in  conjunction  with  other  means 
more  strictly  surgical.  For  example,  Martin,-  of  Bordeaux,  after 
having  practised  ablation  of  the  growth,  made  several  successive 
cauteries  on  the  site  of  the  corneal  implantation,  by  means  of  a 
strabismus  hook  heated  to  redness  in  the  flame  of  a  spirit  lamp. 
Panas^  did  the  same,  only  with  an  olive-tipped  thermocautery. 
Chibrct^  made  a  similar  operation  to  that  of  Galezow^ski,  just  men- 
tioned, but  before  rolling  the  pterygium  upon  itself,  he  applied  the 
galvano-cautery  to  its  posterior,  or  raw,  surface.  This  was  supposed 
to  hasten  the  atrophy  of  the  growth.  Deschamps^  affirmed  that 
cauterism  of  the  corneal  portion,  when  well  done,  especially  if 
combined  with  a  good  scraping,  rendered  any  sort  of  conjunctival 
autoplasty  inutile,  and  that  the  cure  was  rapid  and  permanent. 
Most  all  authorities  agree  that  it  is  highly  indiscreet  to  cauterize 
the  episcleral  part  of  the  wound  opening.  It  should  also  be  borne  in 
mind  that  the  electric  cautery  is,  in  this  respect,  an  instrument  whose 
emplovment  should  be  confined  to  the  most  experienced  and  skillful 
hands,  as  in  any  other  than  these,  because  of  its  tremendous  energy, 
its  work  is  sure  to  be  overdone  and  deep  scars  be  the  result.  Unless 
one  is  sure  of  himself,  it  were  better  to  employ  for  the  purpose  the 
iron  made  red-hot  in  the  flame.  The  actual  cautery  is  particularly 
helpful  in  getting  rid  of  the  infiltrated  head  that  sometimes  thwarts 
one's  efforts  at  dissection  and  scraping,  and  whose  complete 
removal  is  of  the  utmost  importance. 

Starkey,*^  of  Chicago,  recommends  the  galvanic  current  for  the 
treatment  of  pterygium,  but  not  to  the  extent  of  actually  burning  the 
growth,  ])ut  for  its  milder  electrolytic  effect.  Among  the  other 
procedures  employed  as  adjuncts  to  pterygium  operations  may  be 
mentioned   conjunctival   autoplasty   by  means   of   mucous   grafts' 

^  Operationslehre,  S.  381. 

2Annal.  d'oculist,  1881,  p.  144- 

3  Maladies  des  yeux,  1894,  t.  ii,  p.  265. 

^Archiv.  d'opht.,  t.  xi,  p.  528,  1891. 

5  Bull,  et  mem.  de  la  Soc.  franc,  d'opht.,  1895,  ]i.  510. 

6  Journal  of  the  Am.  Med.  Association,  Sept.   i  i,   1898. 

7  S.  Klein,  Allgem.  Wiener  med.  Zeitung,  1876,  Nos.  3  and  4. 


fai.sk  pteryc.ium  357 

and  of  Thiersch  skin  grat'ls.^  The  last  menlioiied  took  from  behind 
the  ear  an  epidermic  graft  somewhat  smaller  than  the  scleral  defect, 
and,  in  order  to  prevent  overlapping  of  the  corneal  margin,  fastened 
it  in  with  two  fine  sutures  at  a  little  distance  trom  the  liml)us. 
Grafting  is  applicable  to  cither  ablation  or  transplantation,  and  the 
method  of  Hotz  is  an  excellent  one.  Thin  epidermis  furnishes  more 
suitable  material  for  the  purpose  than  does  mucous  membrane. 
It  is  more  easily  kept  in  position,  it  docs  not  become  red  and 
meaty,  it  is  less  likely  to  perish,  and  its  whiteness,  lying  as  it  does 
upon  the  sclera,  is  a  positive  advantage.  Such  accessory  measures 
are,  of  course,  reserved  for  the  larger  pterygia  only. 

False  pterygium,  also  known  under  the  names  cicatricial 
pterygium,  pscndo-ptcrygium,  and  pterygoid,  refers  to  an  irregular 
growth  of  conjunctiva  taking  place  upon  the  cornea,  as  a  result  of 
burns  and  other  lesions,  and  its  approach  may  be  from  any  direction 
or  from  several  different  points  at  the  same  time.  Under  this  head- 
ing may  also  be  placed  that  unfortunate  class  of  cases  wherein  there 
have  been  recurrences  of  the  pterygium  after  operations  for  its  re- 
moval, and  there  is  a  sclerotic  degeneration  of  the  cornea,  or  a  condi- 
tion resembling  the  so-called  keloid  cornea.  Where  these  are  present, 
are  not  progressive,  and  the  sight  is  not  greatly  diminished  in  conse- 
quence, one  would  better  abstain  from  further  operative  measures. 
The  exaggerated  forms  tend  more  or  less  to  restrict  the  movements 
of  the  globe  and  to  produce  strabismus,  which  constitute  additional 
indications  for  surgical  intervention;  and  they  are  often  associated 
with  symblepharon  (symblepharo-pterygium).  In  its  surgical  treat- 
ment, therefore,  false  pterygium  involves  many  of  the  principles 
which  are  concerned  in  operations  for  symblepharon  as  well  as  most 
of  those  just  described  in  connection  with  the  true  form.  No  set 
methods  can  be  laid  down  for  their  operative  handling,  as  they 
present  so  great  a  variety  that  each  case  must  be  separately  reckoned 
with. 

Great  care  should  be  exercised  in  the  process  of  uncovering  the 
cornea  where  the  destruction  of  that  membrane  has  been  deep,  lest 
the  anterior  chamber  be  opened.  Oi)lical  iridectomy  is  occasionally 
required  in  connection  with  cicatricial  pterygium. 

The  tendency  of  pterygium  to  return  after  operations,  seems  to 
depend  upon  the  manner  of  its  removal.  Failure  to  cure  does  not 
hang  so  much  upon  the  specific  method  that  is  chosen,  nor,  as  was 

1  F.  C.  Hotz,  of  Chicas:;o,  Klin.  Monatsl)!.  f.  Au.L,uMih.,  i8q7,  p.  6io. 


358  OPERATIONS    UPON    THE    CONJUNCTIVA 

formerly  supposed,  upon  any  inherent  proneness  of  these  growths  to 
recidivate,  as  upon  the  neglect  or  the  lack  of  certain  essential  condi- 
tions. Among  the  causes  of  non-success  stress  is  laid  upon  the 
following : 

(a)  Failure  to  properly  cover  the  scleral  defect  or  so  to  iix  the 
covering  as  to  keep  it  away  from  the  cornea. 

(b)  Incomplete  removal  of  the  growth  from  the  cornea,  especially 
the  head. 

(c)  Want  of  care  in  placing  the  conjunctival  sutures.  Pulling 
and  tearing  the  delicate  membrane,  using  needles  and  thread  that  are 
too  large,  and  taking  with  them  bites  that  are  insufficient. 

(d)  Leaving  a  thick  growth  of  episcleral  tissue  at  the  corneal 
margin. 

(e)  Operating  when  the  whole  conjunctiva  is  hyperemic  or 
inflamed. 

(/)  Inadequate  bandaging  and  allowing  the  patient  too  much 
liberty  during  the  first  few  days  after  the  operation. 

The  causes  (a)  and  ((/)  are  those  that  are,  perhaps,  most  often 
operative.  After  having  removed  a  pterygium,  no  matter  by  what 
method,  if  the  sclera  adjacent  to  the  cornea  is  left  exposed  over  an 
area,  say  of  one-half  a  square  centimeter,  the  defect  were  better 
covered  at  once.  A  most  satisfactory  manner  of  doing  this  is  by 
means  of  a  Thiersch  graft,  as  first  practised  by  the  late  Professor 
Hotz,  of  Chicago.  The  graft  is  taken  from  the  inner  side  of  the 
upper  arm  or  from  behind  the  ear,  and  is  cut  so  that  it  bridges  the 
conjunctival  gap  in  the  vertical  sense,  but  is  narrower  in  the  lateral 
sense.  It  is  placed  in  the  middle  of  the  scleral  defect  and  held  in 
position  by  two  sutures,  one  above  and  one  below.  Thus  the  graft 
keeps  clear  of  the  cornea.  Thiersch  epidermic  grafts  are  preferable 
to  those  that  are  shaved  from  the  mucous  membrane  of  the  mouth, 
because  they  remain  white,  while  tlie  mucous  grafts  never  lose  their 
redness.  Besides,  the  latter  do  not  lie  so  smoothly,  but  become 
bunchy  from  thickening,  and  from  lateral  contraction.  It  is  of 
the  utmost  importance  that  the  patient  be  instructed  to  clean  the 
dead  epithelium  from  the  graft  every  day  or  two  with  warm  boric 
acid  solution  and  a  cotton  swab. 

The  other  cause  of  recurrence  referred  lo  under  (d) — leaving  a 
thick  growth  of  ei)iscleral    tissue  al)out    the  corneal  margin — can 


RECURRENT  PTERYGIUM  359 

be  rendered  inoi)erative  by  scrajMnj^  away  this  growth  very  thor- 
oughly, leaving  the  sclera  quite  bare. 

Gifford/  of  Omaha,  in  an  article  on  "Recurrent  Pterygium," 
cites  Knapp's  well-remembered  warning,  viz.,  "Pterygia  that 
have  relapsed  after  one  or  several  operations  and  have  the  aspect  of 
a  keloid  scar  should  not  be  meddled  with."  Gifford  then  says, 
"The  condition  of  this  class  of  patients  is  so  dei)lorable  that  it 
would  be  unfortunate  if  this  verdict  of  so  high  an  authority  should 
be  considered  final.  1  hiwe  seen  several  of  these  cases,  and  my 
experience  has  led  me  to  an  entirely  different  opinion."  And, 
further,  "My  experience  indicates  that  all  of  these  bad  cases  of 
recurrent  pterygium  can  be  cured  if  a  large  enough  Thiersch  llap 
or  epithelial  lip-flap  is  ])ut  on.  In  doing  the  operation  it  is  impor- 
tant, in  dissecting  back  the  conjunctiva,  to  clean  the  cornea  and 
sclera  very  thoroughly  and  to  be  sure  that  the  flap  is  well  attached 
to  the  globe  before  the  lids  are  allowed  to  close.  The  device  which 
I  have  adopted  of  fixing  the  globe  in  a  position  of  abduction  by 
means  of  a  guy-thread  put  through  the  tendon  of  the  external 
rectus  and  fastened  to  the  skin  outside  the  external  canthus  with 
coUodionized  gauze  to  prevent  displacement  of  the  flap  may  be 
necessary  in  some  extreme  cases.  But  if  the  flap  is  pressed  down 
firmly  with  an  absorbent  cotton  toothpick  swab,  slightly  moistened, 
so  as  to  bring  its  entire  under-surface  into  close  contact  with  the 
globe,  and  the  lids  are  held  open  for  three  to  five  minutes  thereafter, 
then  both  eyes  kept  closed  with  a  rather  firm  bandage,  with  plenty 
of  cotton,  for  48  hours,  failures  from  displacement  of  the  flap  will 
be  rare." 

In  a])plying  the  latter  it  is  sometimes  necessary  to  tuck  the  edges 
in  under  the  loosened  conjunctiva,  and  I  have  once  or  twice  protected 
the  well-applied  flap  by  temporarily  drawing  the  conjunctiva  partly 
over  it  with  a  suture.  The  flap  should  be  slid  directly  from  the 
razor  to  the  globe.  It  should  be  cut  large  enough,  and,  after  cover- 
ing the  defect  on  the  globe,  the  excess  on  the  temporal  side  is  trimmed 
off  so  as  to  leave  bare  the  cornea  and  a  strip  of  sclera  about  1/16 
inch  wide  between  it  and  the  flap." 

What  appears  at  a  glance  to  be  a  recidivation  is  sometimes  but 
the  vascularized  and  otherwise  changed  condition  of  the  cornea 
in  the  locality  that  had  been  occupied  by  the  pterygium.  This  may 
or  may  not  wholly  clear  up.     The  immediate  status  of  the  vision 

1  Ophthalmic  Record,  Jan.,  1909. 


360  OPERATIONS    UPON    THE    CONJUNCTIVA 

after  the  removal  of  pterygia  that  encroach  even  very  shghtly  upon 
the  pupillary  area  is  apt  to  be  disappointing,  owing  to  the  fact  that 
there  is  usually  some  disturbance  of  the  cornea  which  extends  be- 
yond the  apparent  limits  of  the  growth.  A  little  time  is  required 
for  this  to  disappear. 

PERITOMY  AND  PERIDECTOMY. 

According  to  the  researches  of  Hirschberg  the  Arabian  surgeons,  early  in 
the  Middle  Ages,  made  circumcision  of  the  cornea  for  the  pannus  of 
trachoma. 

In  the  year  1862,  Fournari  or  Furnari,^  of  Paris,  afterward  of  the 
University  of  Palermo,  published  the  description  and  the  results 
of  his  experience  with  an  operative  measure  which  he  claimed 
to  have  employed  with  success  while  previously,  for  twenty 
years,  a  resident  of  x\lgeria.  The  author  called  it  tonsure  de  la 
conjondive  bulbaire.  It  consisted  in  the  excision  of  a  ring  of  the 
conjunctiva  immediately  surrounding  the  cornea  and  the  applica- 
tion of  nitrate  of  silver  to  the  annular  defect,  together  with  the 
scarification  of  the  anomalous  corneal  blood-vessels.  Afterward 
the  operation  was  named  peridectomy,  and  still  later  syndectomy, 
both  of  which  words  refer  to  the  removal  of  the  aforesaid  ring  of 
conjunctiva,  and,  strictly  speaking,  should  be  so  used  in  contradis- 
tinction to  peritomy. 

This  last  is  a  term  that  was  applied  by  Critchett,  of  London,  to  a 
modiiication  of  Furnari's  operation,  which  he  devised.  The  chief 
change  suggested  by  Critchett  was  that  the  word  implies,  viz.,  the 
substitution  of  a  simple  circum-corneal  incision  for  the  excision. 
What  Critchett  really  did,  then,  was  to  rehabilitate  the'old  Arabian 
measure. 

The  indications  for  peritomy  and  for  peridectomy  or  syndectomy 
are  the  same,  to  wit,  a  pertinacious  vascularity  of  the  superficial 
portion  of  the  cornea,  whether  consecutive  to  trachoma,  interstitial 
keratitis,  leucoma,  or  aught  else.  The  measure  has  also  been 
resorted  to  with  marked  success,  especially  in  Great  Britain,  for 
episcleritis,  iritis,  herpes  ophthalmicus,  purulent  conjunctivitis, 
and  even  for  glaucomatous  tension. 

Peritomy  was  further  modified  by  Agnew,  of  New  York,  and  was 

one  of  his  favorite  means  of  dealing  with  persistent  pannus.     Having 

iQaz.  med.  de  Paris,  1862,  Nos.  4,  6,  S,  10,  12,  14  et  Annal.  d'oc,  1863, 
t.  xlix,  ]).  272. 


PKRITOMY  361 

been  the  forluiialc  obscrxcr  of  nnicli  of  .\,!j;ni'\v's  hrilliaiU  work,  the 
present  writer  was  led  to  ado])!  ihe  nuihod,  has  employed  it  many 
times,  and  almost  in\-ariahly  willi  .L;ratif\'ini!;  resuhs.  Il  ma}'  be 
thus  described: 

Agnew's  Method. — ^Thc  eye  is  carefully  cleaned  and  put  under 
cocain  anesthesia.  The  lids  are  held  apart  by  the  blepharostat. 
The  globe  is  fixed  and  the  conjunctiva  manipulated  with,  delicate 
mouse-tootli  forceps.  The  conjunctiva  is  incised  all  the  way  around 
with  a  |)air  of  small  curved  scissors  whose  points  are  slightly 
blunted,  but  wdiose  cutting  power,  especially  at  the  extremities  of 
the  blades,  is  absolutely  irreproachable.  It  is  advisable  that  the 
cut  be  as  close  to  the  limbus  as  possible,  hence  these  qualities  in 
the  scissors  are  insisted  upon.  Now  the  mouse-tooth  forcei)S  are 
exchanged  for  the  broad-jawed  fixation  forceps. 

While  the  eye  is  steadied  with  these,  the  severed  conjuncti\a 
is  pushed  backward,  all  around,  to  a  distance  of  about  five  milli- 
meters, by  means  of  a  convex-edged  scalpel.  Willi  this  same 
instrument  the  episcleral  tissue  is  also  scraped  away  till  the  sclera 
is  quite  bare  and,  wdiere  practicable,  the  scrapings  are  excised. 
The  larger  trunks  of  the  corneal  vessels  are  gently  scratched  longi- 
tudinally with  the  point  of  the  knife,  or,  what  is  perhaps  better, 
each  of  them  is  touched  where  it  crosses  the  limbus  with  a  small, 
red  hot,  bulbous  electrode.  No  clots  of  blood  nor  shreds  of  fibrin 
should  be  left  about  the  field  of  operation.  The  eye  is  douched 
copiously  with  hot  boric  or  hot  salt  solution,  and  the  regulation 
monocular  netting  bandage  is  put  on.  The  reaction  is  usually 
insignificant.  Upon  removing  the  bandage,  if  it  is  found  that  the 
conjunctiva  is  creeping  forward,  it  were  best  to  loosen  it  up  with 
a  blunt  instrument,  push  it  back,  and  smear  with  vaselin. 

L.  Webster  Fox,i  of  Philadelphia,  has  recently  made  a  plea  for 
the  rehabilitation  of  peridectomy,  and  states  that  in  loS  such 
operations,  performed  by  him  wdthin  the  past  three  years,  the  results 
had  been  most  gratifying.  He  further  states,  "The  operation  as 
performed  at  present  consists  in  excising  a  strip  of  bulbar  conjunctiva 
2  to  5  mm.  wide  surrounding  the  cornea.  The  vessels  on  the  cornea 
at  the  limbus  are  scarified  by  means  of  a  Beer's  knife,  butnocautcrant 
is  employed.  The  eye  is  anesthetized  by  the  instillation  of  cocain 
(5  per  cent,  solution),  and  excessive  hemorrhage  may  be  controlled 
by  the  application  of  adrenalin  solution,  i  to  1000.     This  is  tlie 

1  Annals  of  Ophthalmology,  Oct.,  iqo,^,  p.  615. 


362  OPERATIONS    UPON    THE    CONJUNCTIVA 

operation  referred  to  as  peridectomy,  and  should  always  be  combined 
with  treatment  directed  toward  tlie  underlying  cause  of  the  corneal 
vascularity." 

I  believe  with  Fox  that  the  operation,  whether  it  be  j^eritomy 
or  peridectomy,  particularly  the  former,  has  been  unjustly  maligned. 
Among  those  who  speak  disparagingly  of  it  is  no  less  a  person  than 
Knapp,^  who  says,  "I  have  performed  it  (in  reality  peridectomy)  a 
number  of  times.  The  result  was  too  uncertain  and  the  danger 
of  sloughing  of  the  cornea  was  ever  present.  I  think  the  operation 
has  been  generally  abandoned."  The  last  two  statements  are 
most  surprising.  j\Iost  surprising  still,  the  distinguished  author 
falls  into  the  popular  error  of  confounding  peritomy  with  peridectomy, 
for  he  calls  the  operation  by  the  first  name  and  says  that  it  "consists 
in  the  removal  of  a  strip,  from  5  to  8  mm.  in  breadth,  of  conjunctiva 
around  the  cornea." 

In  view  of  the  fact  that  the  vast  majority  of  cases  wherein  such 
surgery  is  indicated  concerns  eyes  whose  conjunctival  sacs  are 
already  shrunken,  makes  peritomy,  in  my  opinion,  by  far  the  more 
rational  procedure  of  the  two.  Instead  of  sustaining  a  loss  the 
conjunctiva  is  made  to  gain,  in  that  the  pushing  back  of  the  bulbar 
portion  tends  to  deepen  the  previously  contracted  fornices.  As  to 
the  dangers,  I  have  never  seen  any  untoward  consequences  from  the 
operation. 

It  is  generally  admitted,  however,  that  these  measures  are  only 

to  be  resorted  to  when  those  of  a  less  radical  nature  have  failed  to 

restore  to  the  cornea  its  transparency.     According  to  Panas,-  the 

worst  forms  of  pannus — those  known  as  crassus  and  sarcomatoid — ■ 

are  positive  contraindications,  for  which,  among  other  -modes  of 

treatment,  he  suggests  pericorneal  cauterism,  or  igneous  peritomy. 

For  large  scattering  vessels  that  have  become  a  iixture  in  the  cornea, 

I  have  sometimes  caused  their  disappearance  by  destroying  a  small 

section  of  each  trunk  at  or  near  the  limbus  by  means  of  the  galvano- 

cautery. 

1  Norris  and  Oliver's  System,  1898,  p.  853. 
^  Maladies  des  yeux,  t.  ii,  ]).  230. 


ciiArrER  IX. 

THE  SURGICAL  TREATMENT  OF  TRACMIOMA. 

Measures  more  or  less  surgical  have  since  the  earliest  times  been 
employed  for  the  relief  of  this  wretched  malady.  These  measures 
may  Ijc  classed  as: 

1.  Mechanical, 

2.  Chemical. 

3.  Operative. 

Chief  among  the  mechanical  are: 

(a)  Scraping,  or  scratching. 

(b)  Expression,  or  squeezing. 

The  chemical  are: 

(c)  Cauterism. 
.    (d)   Radiation. 

And  the  operative: 

(e)   Curettage. 

(J)  Excision. 

(g)   Canthotomy  (and  canthoplasty), 

(h)  Peritomy  (and  peridectomy). 

It  is  worthy  of  remark  that  all  of  these  measures,  as  used  in  this 
connection,  with  the  possible  exception  of  electrolysis,  radiation 
and  canthoplasty,  are  as  old  as  history  itself,  or  nearly  so. 

I.  MECHANICAL  TREATMENT. 

(a)  Scraping  or  Scratching. — This  is  probably  the  most  ancient 
of  any  of  the  methods  enumerated.  Under  the  same  heading  one 
may  class  massage.  Primitive  peoples  afflicted  with  trachoma, 
in  seeking  relief  from  the  itching  and  otlier  irritating  effects  of 
the  disease,  early  learned  to  evert  the  lids  and  rub  the  granulations. 
For  this  purpose  they  usually  sought  some  implement  with  a  rough 
surface   or   a    sharpish    edge— hg-leaves,   bits   of    broken   ]iottcry, 

363 


364  SURGICAL  TREATMENT  OF  TRACHOMA 

etc.  Capt.  Cook,  on  his  first  visit  to  one  of  the  hitherto  unknown 
isles  of  the  Pacific,  saw  a  native  mother  holding  in  her  lap  a  tra- 
chomatous child  whose  everted  lid  she  scraped  with  a  chip  of  wood.^ 
Hippocrates,  to  remove  the  granulations,  made  use  of  a  tightly 
wound  mop  of  raw  wool.  The  name  of  the  mop  was  Ophthal- 
moxistron,  and  of  the  scrubbing  ophthalmoxysis.  Paulus,  of 
^gineta,  employed  a  similar  instrument  which  he  called  a  blepharo- 
xystron,  and  the  operation  he  named  blepharoxysis.  With  these 
crude  things  they  rubbed  until  they  exposed  the  tarsus,  then  applied 
powdered  drugs  or  the  cautery  to  the  denuded  part.  Severus 
decried  these  rude  procedures,  preferring  massage.  This  was 
either  simple,  that  is,  with  the  bare  finger  or  other  smooth  object, 
or  medicamentous,  that  is,  with  the  addition  of  unguents,  etc.  There 
have  been  numerous  revivals,  within  modern  times,  of  the  exact 
principles  involved  in  these  ancient  practices,  and  to  the  same  end, 
though,  naturally,  with  improvement  both  as  to  the  manner  and 
means.  The  first  modern  revival  by  Woolhouse,  in  England,  at  the 
end  of  the  i8th  century,  yet  with  an  instrument  little  in  advance 
of  the  original  ones,  seeing  that  it  was  a  brush  made  of  barbS  of 
grain.  The  next  was  by  Borelli,  in  1859;  then,  later,  by  several 
others;  and  still  more  recently  (1891)  by  a  number  of  French 
oculists  and  a  few  in  other  countries.  The  French  have  called  the 
process  variously — as  Brassage,  raclagc,  graltage,  etc.  It  is  not  an 
extremely  bad  measure,  but  it  is  far  from  being  as  good  as  some 
others.  That  of  massage,  on  the  other  hand,  is  a  most  excellent 
one;  particularly  the  medicamentous  kind,  recommended  some 
years  ago  by  Below.''  This  consists  in  rubbing  strong  solutions  of 
sublimate,  1-500  up  to  i-ioo,  into  the  infiltrated  conjunctiva. 
After  an  experience  of  ten  years  with  like  methods,  I  most  heartily 
commend  it  to  my  colleagues.  Since  the  introduction  of  the  organic 
silver  preparations  I  have  found  this  form  of  massage  particularly 
effective.  There  is  hardly  a  stage  of  the  affection  to  which  it  is 
not  applicable,  though  it  is  specially  valuable  where  other  means 
are  contraindicated.  The  writer  proceeds  as  follows:  "The  lids 
are  cleansed  externally  with  warm  boric  acid  solution.     They  are 

^  To  prove  that  such  pristine  practices  have  not  wholly  passed,  the 
writer,  not  long  since,  knew  a  young  man  who  carried  in  his  vest  pocket 
a  fragment  of  window-pane  with  which  he  would,  from  time  to  time, 
scratch  the  upper  borders  of  his  inverted  tarsi.  The  trachoma  bodies  in 
this  instance  were  scarred  veterans,  and  the  noise  that  he  made  with  his 
"scratting"  was  anything  but  musical. 

''Jour,  (le  med.  russo,  1885. 


KXl'RKSSION  365 

then  everted  and  a  single  drop  of  adrenalin  solution  i)Ut  onto  the 
conjunctiva.  A  small  hard  mop  is  made  by  winding  absorbent 
cotton  on  the  tip  of  a  carrier.  This  is  dipped  into  a  very  hot  solution 
of  sublimate,  about  1-250  in  strength,  the  lid  is  again  everted  and 
the  affected  conjunctiva  rubbed.  The  rubbing  should  be  lU'ilhcr 
too  delicate  nor  too  rough,  and  not  prolonged  beyond  a  minute  or 
two,  dip])ing  the  mop  in  the  hot  sublimate  now  and  then,  but  never 
leaving  an  excess  of  liquid  on  it,  to  run  down  over  the  cornea  and 
healthy  portions  of  the  conjunctiva.  Then,  without  replacing  the 
lids,  the  whole  mucous  sac  is  copiously  irrigated  for  another  minute 
with  4%  boric  acid  solution,  as  hot  as  can  be  borne.  And,  lastly, 
a  drop  of  cocain  solution  is  put  in.  This  is  repeated  with  two-day 
intervals,  and,  on  the  alternate  days  precisely  the  same  is  done 
excepting  that  a  50%  solution  of  argyrol  is  substituted  for  the 
sublimate.  If  properly  carried  out,  there  is  no  irritation  after  either 
treatment." 

(/;)  Expression  of  the  lymphoid  material  from  the  trachoma 
follicles,  in  order  to  hasten  the  cure,  is  by  no  means  a  recent  idea. 
It  was  formerly  accomplished  by  means  of  the  finger-nails,  and  was 
called  unguipressio.  A  number  of  attempted  revivals  of  it  had 
occurred  in  the  last  century,  as,  for  example,  by  Eble  (1828), 
Pilz  (1854),  and  Cuignet  (1873).  It  was  not,  however,  until  its 
strong  advocacy  by  Hotz,^  of  Chicago,  in  1886,  that  its  day  really 
arrived;  and  it  looks  as  if  it  had  come  to  stay.  Hotz  lirst  used  his 
thumb-nails,  but  soon  had  the  jaws  of  a  pair  of  old  angular  forceps 
made  smooth  for  this  purpose.  If  I  mistake  not,  this  was  the  original 
expression  forceps.  Then  followed,  in  1891,  Prince's  ring-forceps, 
Noyes'  trough-jawed  forceps  and  Knapp's  roller  forceps,  all  in 
quick  succession  (see  Plate  VI).  The  next  year  the  writer  suggested 
a  ring-forceps  made  of  tortoise-shell  as  an  improvement  over  the 
steel,  in  that  it  would  not  admit  of  the  same  forceful  application — 
hence  less  severe.  The  common  fault  of  these  instruments  is  the 
inevitable  traction  exerted  u])on  tlie  membrane  in  stri])ping  the 
follicles. 

Even  that  of  Knapi),  designed  after  the  princi])le  of  a  mangle, 
does  not  overcome  this  objection.  Could  one  invent  a  practical 
roller  forceps  in  which  an  intrinsic  force,  other  than  the  pull  on  the 
handle,  would  impart  the  rotation  to  the  tightly  clamped  rollers,  it 
would  be  ideal.     Say  a  band,  chain,  gear,  or  screw.     Lacking  this, 

1  Archives  of  ( JiilnlKilmolos^V,  vol.  xv,  i8S6,  p.  147. 


366 


SURGICAL  TREATMENT  OF  TRACHOMA 


the  best  and  most  available  instrument  is  the  cxpressor  of  Kuhnt, 
the  working  part  of  which  is  composed  of  two  coapting,  perforated 
metal  plates.  The  perforations  are  so  arranged  that  no  two  come 
opposite,  one  to  the  other,  and  the  expression  is  effected  by  simple 
pression,  i.e.,  without  traction.  In  cases  of  advanced  gelatinous 
degeneration  of  the  fornices,  the  mere  inversion  of  the  lids  causes 


232. — Kuhnt's  expressor. 


laceration  and  bleeding.  For  these  Kuhnt  has  had  constructed 
what,  he  terms  a  modified  expressor,  one  plate  being  perforated  and 
the  other  solid.  This  he  inserts  beneath  the  uninverted  lid,  finds 
the  infiltrated  tissue,  and  makes  gentle  pressure.     The  expressers 


Fig.  233. — Kuhnt's  expressor. 

are  made  of  varying  shapes  and  sizes,  in  order  that  one  may  reach 
any  part  of  the  conjunctival  sac  (Figs.  232,  233,  235  and  236). 

Since  writing  the  foregoing  paragraph  my  attention  has  been  called 
to  an  expression  roller  designed  by  W.  Norton  Whitney,  M.  D.,  of 


Fig.  234. — ]Modifie(l  Knapp  roller  of  Whitney. 

Tokyo,  Japan,  with  the  object  of  obN-iating  traction  on  the  conjunc- 
tiva (Fig.  234). 

In  this  modification  of  Knaj^p's  forceps  one  of  the  rollers  is 
replaced  by  a  fiat  washboard-like  terminal,  over  which  the  remaining 
roller  is  made  to  pass,  so  that  the  fold  of  conjunctiva  between  these 
two  surfaces  can   be  subjected   to  the  necessary  pressure  without 


EXPRESSION  367 

pulling  or  stretching  it  unduly.  This  motion  is  ohtained  by  means 
of  a  double  hinge  at  the  v\u\  furthest  t'roin  the  roller.  The  pieces  of 
this  end,  which  are  usually  welded  together,  are,  in  the  modified  form, 
separated  by  a  piece  of  metal  three-eighths  of  an  im  h  long,  which  is 
connected  by  hinged  ])()ints  with  the  arms  of  the  forceps. 

The  forceps  are  held  in  the  o])erator's  hand  somewhat  as  a  j)en- 
holder  is  held  when  writing.  A  ring  in  the  u|)per  roller  arm  for  the 
index  finger  and  a  little  boss  on  the  lower  or  tlal  terminal  arm  enable 
the  operator  to  keep  the  instrument  steady. 

Expression  is  highly  efficacious  in  selected  cases.  It  shortens  the 
course  of  trea  ment,  forestalls  ulceration  of  the  cornea,  ])revents 
pannus,  and  reduces  cicatricial  contraction  to  the  minimum.  It  is 
almost  painless  under  the  topic  application  or  the  submucous 
injection  of  cocain.  It  is  simple  of  execution,  and  safe  as  to  con- 
sequences. Patients  may  be  operated  on  and  allowed  to  depart 
at  once  for  home,  provided  they  live  within  calling  distance,  being 
instructed  to  keep  quiet  meanwhile  and  to  bathe  the  lids  with  very 
hot  water.  For  it  must  not  be  understood  that  they  need  no  after- 
treatment.     For  one  thing,  it  must  be  [particularly  seen  to  that  ad- 


llF-«l«!liil^= 


Fig.  235. — Kuhnt. 

hesions  do  not  form  between  contiguous  portions  of  the  membrane 
made  raw  by  the  operation.  To  this  end,  during  the  lirst  days 
thereafter,  frequent  examinations  and,  mayhap,  the  use  of  a  probe, 
are  needed  to  prevent  the  formation  of  cavities  and  pockets.  These 
would  only  help  to  obliterate  the  already  shallowed  cul-de-sacs. 
Repetitions  of  expression  are  rec^uired  as  long  as  any  lurking 
follicles  can  be  discovered,  always  with  a  wholesome  mistrust  of  the 
fornices  and  the  semilunar  fold;  and  appropriate  medical  treatment 
is  to  be  continued  until  the  cure  is  complete. 

The  technic  of  the  process  of  necessity  varies  somewhat  with 
the  kind  of  instrument  employed,  but  is  mainly  such  as  common 
sense  and  a  thorough  knowledge  of  the  nature  of  the  disease  and  of 
the  tissues  involved  would  dictate.  The  principal  things  to  be 
avoided  are  undue  traumatism  of  the  conjunctiva  and  injury  to  the 


368  SURGICAL    TREATMENT    OF    TRACHOMA 

corneal  epithelium.  The  prolonged  action  of  cocain,  it  must  be 
remembered,  is  bad  for  the  cornea.  Every  infiltrated  follicle  must 
be  sought  out  and  emptied  at  the  one  sitting.  After  finishing  and 
before  replacing  the  lids,  free  irrigation  of  the  entire  conjunctival 
surface  with  hot  boric  acid  or  normal  salt  solution  is  indispensable. 
The  time  for  expression  is  toward  the  end  of  the  first,  or  at  the 
beginning  of  the  second,  stage  of  the  disease,  i.e.,  when  the  granules 
have  become  soft  or  "ripe."  This  condition  occurs  when  the  in- 
filtrated follicles  take  on  a  grayish  or  yellow-gray  tint.  Then  the 
affected  folds  and  lobules  of  the  fornices  are  plump  but  quiet.     It  is 


[^^^"■■■■^ 


Fig.  236. — Kuhnt. 

then  that  the  trachoma  bodies  assume  the  appearance  so  often  re- 
ferred to  as  that  of  "frog-spawn"  and  of  "boiled  sago."  All 
authorities  agree  in  advising  against  expression  in  acute  trachoma, 
or  during  the  first  half  of  the  chronic  stage,  or  in  a  blennorrhagic 
period,  be  it  in  the  beginning  or  during  an  exacerbation.  The  most 
violent  outbreaks  call  for  the  mildest  measures.  This  is  one  in- 
stance where  a  desperate  case  does  not  demand  a  desperate  remedy. 

2.  CHEMICAL  TREATMENT. 

(c)  Cauterism.— In  its  broadest  sense  this  termrefers  to  the  use  of 
both  escharotic  mineral  substances  or  caustics  and  the  actual  or 
thermic  cautery.  Caustics  will  not  be  considered.  The  ancient 
Greeks  and  Romans  and  the  physicians  of  the  Middle  Ages  regularly 
resorted  to  cauterization  for  affections  of  the  conjunctiva,  and  often 
in  conjunction  with  scraping  or  scarifying.  To  judge  from  de- 
scriptions in  their  writings,  of  the  implements  with  which  it  was 
done,  and  from  relics  of  the  same  that  have  been  preserved,  they 
seem  to  have  taken  great  pride  in  these  outfits.  The  first  in 
modern  times  to  employ  the  cautery  for  trauchoma  was  Samel- 
sohn,  in  1857.  He  selected  the  more  advanced  cases  for  its  applica- 
tion, touching  the  separate  follicles  with  a  tiny  tip  of  a  galvano- 
cautery  (punctate  cauterization).  Reich  (1888)  and  Burchart 
(1889)  were  strong  sui)j)orters  of  the  galvano-cautery  for  trachoma. 


CURETTAGE  369 

but  rightly  limited  its  use  to  the  recent  cases.  Indeed,  it  is  ad- 
missible at  an  earlier  stage  than  any  other  surgical  measure.  For 
the  extensive  inliltrations,  to  be  ])roperly  applied,  it  is  very  tedious, 
requiring  many  sittings.  But  for  isolated  granules  and  as  an 
auxiliary  to  other  forms  of  treatment,  it  is  most  excellent.  To 
hasten  matters,  (i.  J. indsay- Johnson,  of  London,  has  resurrected 
the  ancient  combination  of  scarification  and  cauterism,  first  in- 
cising the  conjunctiva  horizontally  with  his  triple  knife  and  then 
tracing  the  cuts  with  electrolysis.  Neither  thermic  nor  galvanic 
cautery  nor  electrolysis  have  had  many  partisans  of  late.  They 
mostly  add  to  the  scarring. 

((/)  Radiation. — Much  is  hoped  for  in  the  treatment  of  trachoma 
or,  rather,  much  has  already  been  accomplished  and  much  more  is 
hoped  for  from  the  comparatively  new  therapeutic  agents — X-rays 
and  radium.  Like  caustics,  they  hardly  have  a  place  in  this  treatise, 
and  the  reader  is  referred  for  details  of  their  management  to  other 
sources.  Sufhce  it  to  state  that  none  but  those  thoroughly  con- 
versant with  the  properties  of  these  subtle  things  should  attempt  to 
avail  themselves  of  their  virtues,  for  they  are  as  potent  for  evil  as  for 
good. 

3.  OPERATIVE  MEASURES. 

(e)  Curettage. — Along  with  this  goes  scarification,  and  both 
are  but  phases  of  primitive  methods,  such  as  pricking,  scratching, 
and  scraping.  The  Arabian  surgeons  Isaac  Judeus  and  Rhazes, 
a  thousand  years  ago,  recommended  the  sharp  spoon  for  getting 
rid  of  trachomatous  follicles.  Its  use  was  again  brought  to  the 
front  by  Bardenheuer,  of  Cologne,  in  1877.  The  best  known  and 
most  approved  method  of  employing  it  is  that  of  Sattler,  of  Leipsig. 
After  incising  each  individual  follicle,  this  surgeon  proceeded  to 
lade  out  its  contents  with  a  very  small  curet.  Like  cauterism,  it  is 
not  adapted  to  voluminous  infiltrations  because  of  its  tediousness 
and  the  increased  cicatrization  that  it  causes.  Unlike  it,  however, 
it  is  not  suited  to  the  earliest  stages,  but  to  the  scattering  granula- 
tions that  have  escaped  other  kinds  of  treatment. 

(/)  Excision. — The  fornices,  especially  the  upper,  are  the  store 

houses  or  reserve   stations   of   the  trachomatous   infection.     And, 

as  regards  resistance  to  the  attacks  of  any  ordinary  antagonist,  the 

deeper  recesses  of  the  upper  fornix  are  veritable  strongholds.     They 

24 


370 


SURGICAL  TREATMENT  OF  TRACHOMA 


often  successfully  resist  all  medical  and  mechanical  treatment. 
ll  is  from  these  that  start  the  relapses  that  have  made  the  han- 
dling of  these  cases  so  discouraging.  Not  only  does  the  upper 
fornix  afford  the  best  harbor  for  the  poisonous  germs,  but  the  best 
soil  as  well.  So  that,  when  cured  cases  are  again  exposed  to  a 
trachomatous  environment,  the  upper  fornix  has  been  oftenest  the 
site  of  a  reinfection.  Knowing  these  things  doubtless,  as  well  as  the 
fact  that  the  cutting  out  of  a  fold  of  swollen  or  infihrated  conjunctiva 
is  often  mentioned  in  the  Hippocration  and  other  old  medical 
writings,  may  have  been  the  motive  behind  the  active  recourse  to 
surgery  in  fighting  the  tremendous  epidemic  of  trachoma  that  in 
Europe  followed  the  Wars  of  the  Empire.  It  is  certain  that  these 
considerations  actuated  Bendedict,  in  1822,  to  remove  an  occasional 
fold  from  the  cul-de-sac,  and  Galezowski,  in. 1874,  to  excise  the  three 
upper  retro-tarsal  folds  bodily.  Galezowski's  experiences  with  the 
measure  must  have  proven  most  satisfactory,  for  he  has  been  in- 
dustriously at  it  ever  since.  Who  has  not  seen  the  cavalier  manner 
in  which  he  went  about  it! 

Seeing  that  the  tarsus  was  also  often  the  seat  of  the  trachomatous 
affection  and  its  complications,  Heisrath,  of  Konigsberg,  a  pupil 
of  Jackson,  in  1882,  proposed,  in  fit  cases,  adding  to  the  exsection 
of  the  fornix  that  of  the  diseased  portion  of  the  adjoining  tarsus. 
Heisrath's  idea  was  taken  up  and  elaborated  by  \^ossius  and  by 
Kuhnt.  The  last-mentioned  has  been  especially  instrumental  in 
furnishing  details  as  to  the  indications  and  in  working  out  an  ap- 
proved technic.  So  closely  identified  is  the  School  of  Konigsberg, 
i.e.,  now,  Professor  Kuhnt,  with  everything  pertaining  to  trachoma 
and  its  handling  that  it  (or  he)  is  rather  looked  to  as  the  fountain- 
head  of  such  lore.  It  is  to  this  source,  therefore,  that  the  author  is 
indebted  for  most  of  what  follows  on  this  subject. 

In  this  connection  there  arc  three  kinds  of  excision,  to  wit: 

1.  Simple. 

2.  Isolated. 

3.  Extirpation. 

I.  Simple  excision  means  tlie  removal  of  a  strip  of  the  infiltrated 
conjunctiva,  its  dimensions  being  regulated  by  the  requirements 
l^resent.  Kuhnt  restricts  its  application  almost  exclusively  to  the 
lower  fornix.     Its  indications  are: 


EXCISION    OF    TARSLS  37 1 

First. — \\'hcn  the  other  methods  ha\e  failed  or  when  there  are 
recidixations. 

Second. — When  the  tarsus  or  llie  bulbar  ronjuncli\a  are  be- 
coming involved. 

Third. — When  there  are  corneal  complications. 

Fourth. — When  the  i)atient  comes  from  a  trachomatous  district 
and  will  go  back  lo  il.  The  operation  is  contraindicate;l  when  the 
conjunctiva  is  at  all  scant. 

Technic  of  Simple  Excision,  Lower  Lid.  —A  few  minims  of  a 
io%  cocain  solution  are  dropped  into  the  conjunctival  sac,  and 
a  few  drops  of  a  6%  solution  of  the  same  are  injected  into  the  folds 
themselves.  The  upper  lid  is  held  back  by  an  assistant  with  a 
sublimated  cotton  sponge.  The  patient  is  made  to  look  far  up- 
ward, the  operator  e\'erts  the  lower  lid  with  his  left  hand,  while  with 
his  right  he  takes  a  pair  of  curved  scissors,  places  them,  convexity 
downward,  on  the  conjunctiva,  and  begins  the  incision  from  the 
outer  side.  The  plica  semilunaris,  if  also  affected,  would  better  be 
left  for  another  sitting.  If  deemed  necessary  to  excise  it  at  once, 
the  resulting  wound  should  not  be  continuous  with  that  in  the 
fornix,  else  an  ugly  scar  will  ensue.  Sutures  are  usually  omitted. 
After  the  instillation  of  atropin  and  dusting  the  opening  with 
airol,  the  eye  is  bandaged.  The  dressings  are  removed  at  the  end 
of  48  hours,  and  the  conjunctiva  is  washed  with  sublimate  solution, 
1-5000. 

2.  Combined  excision  consists  in  cutting  out  the  trachomatous 
transition  folds  together  with  the  atlected  part  of  the  adjacent 
tarsus,  and  its  sphere  is  limited  to  the  upper  lid.  The  lower  tarsus 
never  requires  exsections.  The  indications  for  this  muco-tarsal 
excision  are: 

First. — In  all  chronic  forms  of  trachoma,  with  characteristic 
follicles,  associated  with  intlltration  of  the  tarsus,  whether  the 
cornea  is  involved  or  not. 

Second. — In  extensive  chronic  trachoma  of  the  fornices  and  palpe- 
bral conjunctiva,  independent  of  the  condition  of  the  tarsus,  if 
the  cornea  is  involved  or  about  to  be. 

Third. — In  gelatinous  trachoma,  even  when  mainly  confmed  to 
the  iornices,  if  the  convex  edge  of  the  tarsus  shows  typical  thickening. 

Fourth. — In  already  cured  trachoma  of  the  fornices  if  the  jialpe- 
bral  conjunctiva  and  tarsus  are  gelatinous — especially  if,  in  addition, 
there  is  secondarv  affection  of  the  cornea. 


372  SURGICAL  TREATMENT  OF  TRACHOMA 

The  conlraindications  are: 

First. — Recent  cases  without  corneal  com])Hcalions. 

Second. — The  achent  of  the  stage  of  scarring,  and  the  granular 
process  has  ceased  or  is  in  the  act  of  ceasing. 

Third. — ^Marked  tendency  to  shrinkage  (Xerosis)  of  the  con- 
junctival sac. 

Technic. — The  eye  is  prepared  as  for  simple  excision.  The  upper 
lid  is  everted  and  two  pairs  of  special  fixation  forceps,  with  catches, 
are  made  to  grasp  the  tarsus  near  its  extremities,  in  the  horizontal 
sense,  and  are  locked.  An  assistant,  standing  at  the  patient's 
head,  takes  the  forceps  and  rotates  them  so  as  to  still  further  turn 
the  lid,  the  patient  meanwhile  being  directed  to  look  forcibly  down- 
ward, thus  bringing  the  fornix  into  view.  The  first  incision,  through 
conjunctiva  only,  is  parallel  with  the  convex  border  of  the  tarsus, 
and  far  enough  back  to  include  the  diseased  folds.  The  purplish 
muscle  of  Miiller  is  here  to  be  avoided.  Three  sutures  are  now  put 
through  the  posterior  lip  of  the  wound  from  the  epithelial  side,  and 
it  is  undermined  nearly  to  the  globe,  while  making  traction  on  the 
threads.  The  two  forceps  are  now  removed,  the  operator  seizes 
the  free  border  with  a  Blomer's  forceps  and  the  aid  places  a  Jager 
spatula  behind  the  inverted  lid  as  a  support  for  the  second  or  tarsal 
incision.  This  begins  at  the  inner  and  extends  to  the  outer  canthus, 
uniting  the  extremities  of  the  first  incision,  and  includes  both  con- 
junctiva and  tarsus.  It  curves  slightly  toward  the  first  incision  so 
as  to  leave  greater  width  of  tarsus  at  the  center.  The  widest  part 
of  the  island  thus  surrounded  should  not  be  more  than  i  1/2  to  2 
centimeters.  The  tarsal  portion  of  the  island  is  carefully  dissected 
out  with  blunt-pointed  scissors,  hugging  the  outer  surface  of  the 
tarsus,  and  avoiding  the  orbicularis  and  the  muscle  of  ]Mullcr.  The 
lid  is  closed,  the  sutures  drawn  down  straight,  the  point  where  each 
emerges  from  the  free  border  is  noted,  the  lid  turned  back,  and  the 
needles  put  through  the  remaining  strip  of  tarsus  at  the  points  indi- 
cated, coming  out  on  the  conjunctival  surface.  The  threads  are 
tied  in  single  knots,  the  lid  again  turned  down,  and  the  patient 
directed  to  open  and  close  the  eyes.  If  there  be  any  puckering  of 
the  lid,  it  may  be  best  to  evert  and  make  further  dissection  of  the 
posterior  fiap  before  tying  finally.  Ends  of  thread  an  inch  long  are 
left  to  facilitate  removal.  Before  the  bandage  is  applied  scopolamin 
is  instilled  and  airol  dusted  on.     The  bandage  is  changed  on  the 


EXCISION   OF   TARSUS 


373 


third  day,   and  on  the  sixth  chiy  the  sutures  are  removed  and   the 
bandage  left  off. 

The  author  has  made  a  number  of  these  combined  excisions  at 
the  Illinois  Eye  Infirmary  during  the  ])ast  five  or  six  years,  and 
would  suggest  certain  modifications  of  the  technic  as  just  given. 
First,  with  regard  to  the  fixing  and  everting  of  the  upper  lid.  Instead 
of  Kuhnt's  forceps,  which  are  hurtful,  and  in  the  way,  a  Walker  lid 
evertcr  is  used  (Fig.  237).  This  instrument  is  wonderfully  effective 
and  convenient.  An  assistant  can  hold  it  with  one  hand  and,  by 
simple  twisting  or  rolling  movements,  can  give  any  degree  of  eversion 
desired,  and  can  expose  the  fornix  "perfectly.     I  consider  it  more 


Fig.  237. — Walker's  lid  everter. 


efficient  than  a  retractor,  or  a  Groenholm  spoon,  or  any  other  form 
of  everter  I  have  yet  seen.  Second,  as  concerns  the  incision  through 
the  tarsus.  Instead  of  making  it  perpendicular  to  the  plane  of  the 
tarsus,  he  would  make  it  slanting  upward,  as  shown  in  Fig.  238,  where 
the  heavy  black  line  indicates  the  parts  excised.  This  conduces  to 
less  unevenness  in  the  resulting  cicatrix.  Third,  as  to  the  placing 
and  tying  of  the  middle  suture.  The  usual  way  is  to  pass  them  first 
through  the  flap,  from  the  conjunctival  surface,  then  through  the 
remnant  of  the  tarsus  to  emerge  and  be  tied  on  the  conjunctiva. 
Now,  to  avoid  contact  of  the  knots  with  the  cornea,  which  is  danger- 
ous as  well  as  painful,  he  would  advise  the  use  of  a  fine,  double-armed 
suture,  introduced  as  follows:  one  needle  is  passed  through  the  flap  of 
conjunctiva  from  the  epithelial  side,  then  through  the  remnant  of 
tarsus,  coming  out  at  the  free  border  almost  in  line  with  the  cilia 
(Fig.  239).  The  other  needle  is  made  to  pass  through  the  tarsus 
in  a  similar  manner,  but  slightly  in  front  and  to  one  side  of  the  track 
of  the  first  needle.  Both  needles  are  not  put  through  the  flap  of 
conjunctiva.     The  two  ends  of  thread  are  tied  over  a  long  slender 


374 


SURGICAL    TREATMENT    OF    TRACHOMA 


cylinder  of  gauze  or  absorbent  cotton  that  will  fold  upon  itself 
without  getting  into  the  palpebral  fissure.  Only  one  is  required,  and 
on  either  side  of  it,  one  passed  in  the  ordinary  way.  Or  one  may  bring 
the  ends  of  the  double-armed  suture  out  through  the  skin  near  the 
free  border  where  it  is  tied  over  a  roll  of  gauze.  (Fig.  240.)  The  two 
outer  sutures  are  knotted  in  the  usual  way,  i.e.,  on  the  conjunctival 
surface.  Indeed,  if  the  exsection  of  tarsus  reaches  almost  to  the  free 
border  and,  as  is  often  the  case,  the  angle  there,  with  the  muscle  of 


Fig.  238. — Excision  of  tarsus.     The  heavy  black  line  surrounds  portion 
excised  in  extreme  cases. 


Riolani  has  been  whetted  away,  the  second  needle  is  not  needed — the 
end  of  thread  being  simply  brought  around  to  be  tied  to  its  fellow. 

Kuhnt  considers  the  combined  excision  the  best  prophylactic 
against  pannus. 

3.  Isolated  Excision  of  the  Tarsus. — In  this  i)roce(lurc  all  of 
the  upper  tarsus  but  a  narrow  strij)  at  the  free  border  is  excised; 
but  the  overlying  conjunctiva  is  s])ared.  Kuhnt,  its  author,  considers 
it  valuable  in  the  cicatricial  stage  after  the  original  disease  has 
disappeared,  leaving  a  thick,  infiltrated  tarsus,  exciting  pannus,  and 
as  a  preventive  of  ptosis  and  slow  atrophy.  It  is  also  deemed  useful 
in  cases  of  shrunken  and  incurvated  tarsi,  as  a  relief  from  entropion, 
wliether  or  not  pannus  exists. 


EXCISION    OF    TARSUS 


375 


Fig.  239.— Combined  excision  of  the  tarsus.     Disposition  of  sutures. 


Fig.  240.— Combined  exi  ision  of  the  tarsus.     Showing  the  two  ways  for 
the  central  suture. 


376  SURGICAL  TREATMENT  OF  TRACHOMA 

Technic. — An  assistant  grasps  the  margin  of  the  hd  with  the 
Blomer  forceps,  everts  it,  and  places  beneath  the  now  inverted  tarsus 
the  Jager  spatula.  The  operator  makes  an  incision  through,  and 
the  whole  length  of,  the  tarsus  2  1/2  mm.  from  the  free  border, 
taking  care  not  to  wound  the  fascia  underlying  the  orbicularis.  The 
conjunctiva  is  dissected  from  the  tarsus,  leaving  the  latter  exposed. 
The  cartilage  is  then  separated  from  the  pretarsal  connective  tissue 
up  to  the  convex  border  by  means  of  blunt-pointed  scissors,  and, 
lastly,  it  is  detached  from  the  levator  tendon.  As  a  rule,  sutures  are 
not  required.  The  after-treatment  is  the  same  as  for  the  combined 
excision. 

The  operation  just  described  is,  I  believe,  comparatively  seldom 
resorted  to.  The  combined  excision,  however,  is  in  constant  requisi- 
tion in  Konigsberg.  Kuhnt  alone  has  performed  it  more  than 
5,000  times.     He  sums  up  the  results  thus : 

1.  The  course  of  the  disease  is  shortened,  the  time  required  for  a 
case  being,  on  an  average,  six  weeks,  including  after-treatment. 
He  declares  that  expression  cures  only  10%  of  the  cases,  while 
excision  cures  50  to  60%. 

2.  Secondary  corneal  disease  is  prevented,  or,  when  present  is 
more  quickly  cured. 

3.  The  mechanical  ptosis  is  corrected. 

4.  Recurrences  are  less  frequent. 

The  objections  to  the  measure  that  have  been  urged  are  too  much 
loss  of  conjunctiva,  limitation  of  ocular  movements,  and  serious 
cicatricial  contraction.  To  obviate  the  first,  Kuhnt  operates  only 
upon  eyes  with  sul^cient  conjunctiva.  As  to  the  second  objection, 
he  counsels  the  invariable  conservation  of  the  bulbar  conjunctiva, 
even  when  it  is  infiltrated,  and  treating  it  by  medical  and  mechanical 
methods.  With  respect  to  the  third,  it  is  declared  that  since  only 
portions  of  the  conjunctiva  and  tarsus  are  excised  and  all  the  deeper 
tissues  are  avoided,  the  resulting  scars  are  superficial — hence 
harmless. 

It  is  rather  singular  that  so  few  operations  of  cither  simple  or 
combined  excision  are  made  for  trachoma  in  this  country.  We 
have  large  areas  in  the  State  of  Illinois  where  trachoma  is  endemic 
and  has  been  for  fifty  years  or  more.  Vast  numbers  of  the  victims 
are  treated  both  in  Chicago  and  in  St.  Louis,  yet  one  rarely  hears 
of  even  simple  excision;  more  rarely  of  combined.  Two  reasons 
occur  to  me  for  this:     First,  the  character  of  the  peoj^le.     They  are 


OPERATION   FOR   PANNUS  377 

of  a  peculiar  tyi)c^shiftless  and  ignorant  beyond  belief — and  from 
some  unexplained  cause,  the  majority  come  for  treatment  in  the 
very  last  stages  of  the  disease.  Second,  as  regards  the  minority 
who  come  in  the  early  or  middle  stages,  they  are,  for  the  most  part, 
so  circumstanced,  either  from  being  cared  for  in  a  charitable  institu- 
tion, or  from  having  nothing  to  call  them  home,  that  they  are  content 
to  worry  along  with  conservative  measures.  When  it  comes  to  a 
discussion  of  more  radical  steps  the  surgeon  in  charge,  unlike  our 
European  confreres,  in  like  situations,  has  precious  little  to  say  in 
the  matter.  The  reason  we  do  not  make  enucleation  of  the  tarsus 
(isolated)  oftener  in  these  old  cicatricial  cases  is,  I  fancy,  because 
of  the  high  state  of  efficiency  to  which  the  combination  operations 
for  trachomatous  entropion  and  trichiasis  have  been  brought  in 
the  United  States. 

A  New  Method  of  Operating  in  Pannus. — Primrose,^  William, 
Glasgow.  This  writer  describes  a  very  simple  operation  which  he 
has  found  satisfactory;  it  consists  in  causing  an  extravasation  of 
blood  into  the  subconjunctival  tissue  around  the  cornea,  which  by 
mechanical  pressure  and  irritation  sets  up  localized  inflammation 
and  thus  causes  obliteration  of  the  vessels  which  vascularize  the 
cornea.  The  point  of  a  small  sharp-pointed  knife  is  passed  through 
the  conjunctiva  2  or  3  mm.  from  the  cornea,  made  to  puncture  one 
of  the  large  blood-vessels,  and  then  withdrawn.  The  conjunctival 
wound  should  be  as  small  as  possible  and  oblique;  in  this  way  there 
is  no  external  hemorrhage;  the  subconjunctival  bleeding  is  arrested 
by  pressure  of  the  extravasated  blood  upon  the  vessel  walls,  and  thus 
many  of  the  smaller  vessels  are  closed;  this  mechanical  action  is 
increased  by  the  information  of  a  coagulum,  the  fibrinous  part  of 
which  shrinks. 

"Extravasated  blood  acts  as  an  irritant,  probably  chemical  as  well 
as  mechanical,  so  a  non-infective  inflammation  is  set  up  which  re- 
sults in  the  absorption  of  the  blood-clot.  This  process  acts  as  a 
counterirritation  to  the  inflammation  of  the  corneal  tissues  and  so 
tends  to  remove  the  seat  of  inflammation  and  the  supply  of  blood 
from  the  diseased  cornea  to  the  clot,  where  the  effects  of  the  inflam- 
mation are  comparatively  trivial.  By  the  time  the  blood-clot  has 
disappeared  the  blood-vessels  in  the  cornea  affected  by  the  operation 
have  shriveled  up  and  the  cornea  has  regained  much  of  its  trans- 
parency.    The  whole  pannus  may  be  treated  in  this  way  at  one 

iThe  Lancet,  April  21,  1906. 


378  OPERATIONS    UPON    THE    CONJUNCTIVA 

time  or  the  operation  may  be  repeated  from  time  to  time,  only 
a  part  of  the  pannus  being  treated  each  time.  The  latter  is  always 
advisable  when  the  pannus  is  marked,  as  the  inflammatory  reaction 
is  sometimes  very  severe  and  accompanied  by  a  good  deal  of  pain. 
Ahhough  the  structures  in  the  anterior  part  of  the  eyeball  are  all 
more  or  less  affected  by  the  intlammation,  this  is  easily  controlled 
and  subsides  in  a  few  days  with  the  application  of  suitable  remedies." 
In  the  classification  of  surgical  measures  for  trachoma  given  at 
the  beginning  of  this  chapter  occur  two  other  operative  ones,  viz. : 
(g)  canthotomy  and  Qt)  peritomy.  The  technic  and  the  indications 
for  them  have  been  given  elsewhere  in  this  volume,  and  they  are 
mentioned  here  only  by  way  of  completing  the  list. 


CHAPTER  X. 
OPERATIOXS  UPON  THE  GLOBE. 

FOREIGN    BODIES    IN    THE    CORNEA. 

About  two-thirds  of  all  the  foreign  bodies  that  enter  the  eye  find 
lodgment  in  the  cornea.  Fortunately,  most  of  them  are  tiny 
particles  that  strike  with  feeble  momentum,  such  as  bits  of  cinder, 
iron,  emery,  etc.,  and  do  not  penetrate  beyond  Bowman's  membrane, 
and,  once  located,  their  removal  is  simple.  Whatever  of  difticulty 
attends  the  operation  is,  usually,  that  of  fmding  the  offender  and 
keeping  it  in  view.  A  particle  so  minute  as  to  be  in\-isible  to  the 
unaided  eye  can  be  the  source  of  great  and  prolonged  irritation. 
Such  a  foreign  body  is  particularly  hard  to  see  when  its  color  offers 
no  contrast  to  that  of  the  iris  or  pupil  and  when  it  has  but  recently 
entered  the  cornea.  After  resting  in  the  same  place  a  few  days 
a  tiny  zone  of  gray  infiltration  surrounds  it,  which  serves  better 
to  reveal  its  position.  If  the  characteristic  symptoms  are  present  and 
careful  inspection  in  bright  daylight  and  with  the  use  of  convex 
lenses  and  focal  illumination  fails  to  show  the  foreign  body,  recourse 
is  had  to  artilicial  light  and  the  binocular  loop.  The  patient  is 
placed  where  a  good  artificial  light  is  near  on  the  side  of  the  affected  eye, 
almost  any  kind  of  light  will  do,  but  if  it  be  an  unground  incandescent 
electric  lamp,  it  were  better  to  cover  the  bulb  with  a  sheet  of  white 
tissue-paper.  Again,  oblique  focal  illumination  by  means  of  a  2-  or 
3-inch  biconvex  lens,  of  large  diameter,  while  the  operator  wears, 
strapped  to  his  head,  a  binocular  loop.  Search  is  made  by  directly 
concentrating  the  rays  upon  the  epithelium,  i.e.,  kcc{)ing  the  image 
of  the  lens  as  much  out  of  the  way  as  ])()ssible.  If  this  fails, 
a  broad  image  of  the  lens  is  thrown  on  to  the  cornea,  and  in 
the  area  of  this  reflection  is  sought  a  break  that  might  indicatfl 
the  mote.  Specks  of  transparent  substances,  like  glass  or  sanee 
will  sometimes  elude  any  form  of  seeking  except  the  last.  If  the 
quest  prove  specially  trying,  a  drop  of  1%  fluorescin  solution  ]nit  on 
the  cornea  would  aid  by  causing  a  tiny  green  stain  at  the  site  of  the 
foreign  body.     Throughout  all  the  scrutiny  the  patient  is  told  to 

379 


380  OPERATIONS  UPON  THE  GLOBE 

turn  the  eyes  in  various  directions  to  favor  the  search.  Having  once 
found  the  foreign  body,  it  is  easily  seen  afterward.  If  the  eye  has 
not  already  been  prepared,  it  is  now.  One  should  be  as  scrupulous 
as  to  cleanliness  of  everything  concerned  as  if  for  an  extraction  of 
cataract.  Warm  boric  acid  solution  is  the  best  thing  with  which  to 
bathe  and  douche  the  eye.  Cocain,  or  its  analogue,  is  all  that  is 
needed  in  the  way  of  anesthesia.  I  have  never  yet  had  to  resort  to 
narcosis,  yet  one  can  imagine  how  this  might  become  necessary. 
In  cases  of  little  children,  they  are  put  in  the  position  described 
under  "Applications  and  Dressings."  If  there  be  much  hyperemia, 
a  drop  of  adrenalin  chlorid  or  similar  solution  is  put  in  just  before  the 
anesthetic  to  blanch  the  conjunctiva. 

The  best  all-around  form  of  instrument  is  the  sharp,  grooved 
spud  or  gouge  (Plate  II,  No.  42),  thoroughly  disinfected.  A  dis- 
cission needle  is  also  a  good  instrument,  provided  it  is  not  too  sharp. 
The  foreign  body  being  of  the  kind  that  requires  artilicial  light  to 
show  it,  the  lens  to  illuminate  the  spot  is  held  by  an  assistant.  If 
no  one  is  by  to  help,  the  best  substitute  is  one  of  the  several  forms 
of  lens-holder.  This  is  a  head-band  with  jointed  ball-and-socket 
bracket  for  carrying  the  lens,  and  is  made  fast  to  the  patient's 
head.  If  this  is  not  available,  the  patient,  if  one  of  average  intel- 
ligence, can  be  made  to  focus  the  light,  meanwhile  supporting  the 
hand  that  holds  the  lens  against  the  cheek. 

Mode  of  Procedure  (Fig.  241). — The  patient,  with  a  towel  cover- 
ing the  hair,  is  placed  in  an  ordinary  chair  of  suitable  height,  behind 
which  stands  the  operator.  No  lid  speculum  is  used,  as  this  would 
necessitate  fixation  forceps  also.  The  head  is  held  firmly  against 
the  surgeon's  breast  by  pressure  of  the  base  of  the  left  palm  on  the 
forehead,  while  the  eye  is  held  open  and  the  globe  is  steadied  by 
pressure  of  the  first  and  second  fingers,  the  first  upon  the  upper  lid 
and  the  other  upon  the  lower.  The  patient  is  made  to  look  in  the 
direction  that  gives  the  best  view  of  the  foreign  body,  which  is  lifted 
out  in  such  a  way  as  to  produce  least  disturbance  of  the  corneal 
epithelium.  The  practice  of  using  very  blunt  instruments  or  of 
wiping  the  foreign  body  off  the  cornea  with  a  mop  made  by  wrap- 
ping cotton  upon  some  small  implement  cannot  be  too  strongly 
discouraged.  If  it  be  a  particle  of  iron  or  steel,  a  reddish  stain  will 
be  left  behind;  if  a  cinder  or  bit  of  emery  that  has  entered  the  eye 
while  very  hot,  its  bed  will  be  a  whitish  eschar,  and,  if  some  days 
have  elapsed  since  the  accident,  it  matters  not  what  the  nature  of  the 


rOKKIGN  BODIES  IN  THE  CORNEA 


381 


substance  is,  a  layer  of  softened  tissue  will  surround  the  forei.^m 
l)()dv.  in  e\erv  case  the  little  excavation  should  be  scraped  clean 
by  a  sort  of  rotary  handling  of  the  gouge.  If  this  is  not  done,  the 
condition  of  the  eye  may  be  worse  than  before.  In  the  process  of 
loosening  the  foreign  body  and  cleaning  out  its  bed  it  is  best  that,  in 
a  general  way,  the  movements  of  the  point  of  the  instrument  be 


Fig.  241. — The  removal  of  a  foreign  body  from  the  cornea  hy  the  aid  of  focal 
illumination. 


directed  toward  the  center  of  the  operative  held  and  from  every  part 
of  the  periphery.  Thus  one  avoids  leaving  tags  of  epithelium  and 
iiaps  of  Bowman's  membrane  around  the  place  to  harbor  bacteria 
and  increase  the  dangers  of  infection.  After  the  operation,  another 
copious  douching  of  the  cornea  with  warm  boric  acid  solution  and 


382  OPERATIONS  UPON  THE  GLOBE 

instruction  that  the  eye  be  bathed  a  time  or  two  in  very  hot  water, 
and  all  is  done  that  most  cases  require.  A  class  of  corneal  injury 
common  in  the  United  States  is  that  from  exi)losions  of  gunpowder, 
and  requires  a  management  ({uite  peculiar.  The  unburnt  grains  go 
rather  deeply  into  the  cornea,  but  rarely  perforate  it.  To  dig  at 
them,  particularly  when  the  injury  is  recent,  but  results  in  further 
traumatism  without  attaining  the  main  object.  Even  when  one 
succeeds  in  removing  a  grain,  it  is  broken,  and  a  black  stain  remains 
behind.  It  is  best  to  wait  from  48  to  60  hours,  meanwhile  watching 
the  eye  and  keeping  it  from  infection  by  mild  antiseptics,  and 
under  other  appropriate  treatment,  when  it  will  be  found  that  the 
grains  have  become  loosened.  If  the  eye  is  then  irrigated  copiously 
with  boric  acid  solution,  cocainized,  the  patient  put  in  the  recumbent 
position  and  a  few  drops  of  H^O,  instilled,  the  lids  being  held  apart 
to  allow  the  liquid  to  overlie  the  cornea,  most  of  the  impacted 
foreign  material,  be  it  powder  or  other  debris,  will  come  away.  The 
peroxid  attacks  the  softened  envelope,  and  the  gas  that  is  generated 
forces  the  foreign  body  out.  At  the  same  time,  the  powder  that  is 
in  the  lids  and  face  is  treated  by  rubbing  the  skin  vigorously  with 
absorbent  cotton  wet  with  the  peroxid. 

Larger  foreign  bodies  have  often  to  be  dealt  with  difTerently. 
It  may  be  that  one  has  struck  the  cornea  so  obliquely  and  with  such 
force  as  to  have  plowed  its  way  for  some  distance  beneath  the  sur- 
face. It  were  best  here  to  slit  up  the  track  of  the  foreign  body  before 
attempting  to  dislodge  it.  Or,  again,  a  particle  may  have  stopped 
just  short  of  dropping  into  the  anterior  chamber  and  yet  not  be  ac- 
cessible by  forceps,  and  so  nearly  through  that  it  were  unwise  to  use 
the  gouge.  In  this  case  one  might  have  recourse  to  the  method  of  Des- 
marres,  viz.,  that  of  passing  a  broad  needle  or  Beer's  knife  through 
the  base  of  the  cornea  into  the  anterior  chamber  immediately  beneath 
the  foreign  body.  Upon  the  ensuing  evacuation  of  the  aqueous, 
the  blade  of  the  instrument  will  tend  to  press  the  piece  upward,  and, 
at  the  same  time,  form  a  solid  foundation  upon  which  to  work.  If 
the  foreign  body  be  of  steel  or  iron,  however,  and  so  imbedded  that 
it  cannot  readily  be  got  at  witli  other  instruments,  it  can  surely  be 
removed  by  some  form  of  magnet.  Jf  sufficiently  loose,  a  horse-shoe 
magnet  or  the  Gruening  i^ockel-magnet.  If  more  tightly  fast, 
the  Hirschberg  electro-magnet  or  the  giant  electro-magnet  of  ilaab, 
or  a  modification  of  it.  Traction  should,  of  course,  be  from  the 
same  direction  as  that  in  which  llie  foreign  body  entered.     More 


ABRASION  OF  THE  CORNKA  383 

explicit  instructions  for  the  use  of  ihe  n-ia,u;nel  are  .i^iven  in  the 
chapter  on  "Foreij^n  Bodies  within  ihe  l\ve."  Alropin  and  an 
occlusion  banda,u;e,  in  addition  to  the  mild  anliseplic  irri,n;ali()n , 
are  the  rule  in  the  severe  cases. 


ABRASION  OF  THE  CORNEA. 

This  consists  in  scraping,  shaving,  or  excising  from  the  cornea 
varying  amounts  of  its  substance  for  the  removal  of  o])acities.  It 
is  a  very  old  procedure,  having  been  practised  long  before  Galen's 
time.  This  surgeon  employed  it  for  certain  forms  of  superficial 
corneal  opacity.  Malgaignc^  having  concluded  from  experiments 
u])on  animals  that  half  the  thickness  of  the  cornea  could  be  re- 
moved without  leaving  an  opacity,  proposed  giving  the  opera- 
tion a  much  wider  range  of  application.  Notwithstanding,  the 
fact  remains  that,  owing  to  their  depth  and  the  replacing  of  the 
lost  substance  by  opaque  tissue  again,  very  few  of  the  many  forms 
of  opacity  will  yield  to  such  treatment.  This  is  not  to  say,  how- 
ever, that  the  operation  has  not  a  wide  sphere  of  usefulness. 
This  is  particularly  true  of  the  scraping  method. 

Indications.— It  is  most  frequently  indicated  in  deep  slow 
ulcers,  such  as  those  at  or  near  the  center  that  have  been  left  from 
phlyctenular  keratitis,  the  removal  of  foreign  bodies,  etc.  These, 
being  so  removed  from  the  vascular  zone,  often  become  filled  with 
a  mass  of  detritus  and  all  efforts  at  repair  cease.  It  has  also  been 
extensively  used  in  the  more  active,  infectious  ulcers  of  the  cornea, 
principally  in  the  serpiginous.  Mcyerhofer,-  instituted  a  method  for 
the  treatment  of  such  ulcers  that  has  been  extensively  followed,  viz., 
curetment  of  the  ulcer  and  its  infiltrated  border  with  a  small 
sharp  spoon,  filling  the  remaining  cavity  with  iodoform  ])o\vder 
and  bandaging.  The  lost  substance  is  thought  by  many  to  be 
replaced  much  more  quickly  and  with  less  opacity  after  abrasion 
than  after  the  cautery.  In  the  days  when  collyria  containing  suba- 
cetatc  of  lead  was  such  a  universal  remedy  for  "sore  eyes,"  abra- 
sion was  frequently  and  successfully  called  into  requisition  for  the 
removal  of  the  peculiar,  opalescent  metallic  deposits  they  occasioned. 
One  rarely  sees  them  nowadays.  Other  indications  are  the  thick- 
ened, opaque  ei)ithelium  resulting  from  ])annus,  tlie  so-called  girdle- 

^  Annal.  d'oculist.,  1843-45. 
2  Kl.  Mbl.  F.  A.  S.  151,  1884. 


384  OPERATIONS  UPON  THE  GLOBE 

shaped  opacity,  the  black  film  caused  by  powder  explosions,  and 
characteristic  chalky  deposit  consequent  upon  certain  chronic 
diseases  of  the  eye,  especially  those  of  the  uveal  tract.  This 
deposit,  which  has  also  been  called  "  ribbon-shaped  keratitis,"  is  most 
distinctive  in  appearance,  resembling  nothing  so  much  as  the 
frothy,  glistening  white  stuff  one  often  sees  overlaying  portions  of 
the  cornea  in  elderly  people,  and  that  has  been  expressed  from  the 
Meibomian  ducts.  Leber  has  recently  shown  that  it  is  calcific  de- 
generation of  Bowman's  membrane.  It  yields  readily  to  abrasion. 
The  nebulous  opacities,  which  result  from  superficial  keratitis,  have 
sometimes  been  removed  in  this  way.  Indeed,  as  it  is  a  relatively 
harmless  procedure  when  done  under  favorable  conditions,  it  ought 
oftener  to  be  tried  where  there  is  any  likelihood  of  the  opacity 
being  shallow. 

The  operation  is  simple  and  easy.  Local  anesthesia  is  best 
when  practicable;  when  not,  chlorid  of  ethyl  or  similar  narcosis. 
The  lids  are  parted  by  the  blepharostat  and  the  eye  steadied  with 
fixation  forceps.  The  scraping  instrument  may  be  a  small,  very 
sharp  spoon  or  small  convex-edged  scalpel  that  is  exceptionally 
keen.  In  scraping  it  is  best  to  work  always  from  the  periphery  of 
the  spot  toward  its  center  so  as  not  to  leave  the  edge  of  the  sur- 
rounding layers  loosened  and  lifted  up.  One  has  only  to  scrape 
until  clear  or  sound  cornea  is  reached,  irrigate  thoroughly,  and 
bandage.  A  septic  condition  of  the  conjunctiva  or  of  the  lacrimal 
canal  are  contraindications. 

The  shaving  and  excision  processes  are  not  so  much  to  be  recom- 
mended. In  the  first,  the  opacity  is  pared  away  by  means  of  a 
knife  or  curved  lancet.  In  the  second,  the  edge  of  the  area  is  out- 
lined with  the  point  of  a  knife  and  the  flap  dissected  out  with  tiny 
forceps  and  knife. 

The  Surgical  Removal  of  Corneal  Scars.— Wiener,  of  Saint 
Louis,  [Oph.  Record,  Sept.,  191 1)  read  a  paper,  illustrated  by  lantern 
slides,  before  the  Chicago  Ophthalmological  Society,  May  15,  1911, 
in  which  he  described  a  method  he  had  employed  on  various  animals 
and  man.  It  consisted  of  making  an  incision  perpendicuhir  to  the 
surface  of  the  cornea  along  the  line  of  the  scar;  then  cutting  from  the 
middle  of  this  line  through  the  scar  to  be  removed.  The  cornra  is 
then  picked  uj)  carefully  with  a  sharp  hook  and  dissected  away  until 
it  can  be  more  firmly  grasped  with  a  forceps,  it  Ix-ing  urged  to  keep  in 
the  same  shcalh  in  wliicli  wr  start.     It  is  dilficult  to  gauge  the  first 


CORNEAL    PAUTERY  385 

incision  so  as  to  <^^o  (k-cp  fnou.u;!!  and  \c'l  nol  |)uiu  turc  ihc  Dcscemct's 
membrane.     Ikil  this  skill  is  ac(|uii\(t  with  practice. 

The  after-care  is  just  as  one  would  treat  any  corneal  wound;  the 
less  interference  the  better.     Cleanliness  is  of  paramount  importance. 

The  microscopical  specimens  showed  that  the  epithelium  covers 
the  resected  area  in  from  five  to  se\en  days.  It  e\-entually  assumes 
its  normal  thickness  and  appearance.  The  cornea  proper  ])ecomes 
gradually  clearer  and  thicker,  although  ne\er  attainin.u;  the  normal 
thickness. 

Age  seems  to  have  little  influence  on  the  result,  as  in  one  patient 
on  whom  the  author  operated  two  years  ago  at  the  age  of  69  years, 
the  vision  was  improved  from  hand  movements  to  ability  to  count 
fingers  at  ten  feet,  with  improvement  still  continuing. 

The  photographs  presented  showed  the  appearance  of  rabbits 
with  white  scars  from  cauterization,  and  pictures  taken  later  after 
the  scar  had  been  resected. 

The  point  especially  made  prominent  was  that  the  operator  must 
keep  in  the  same  layer  of  the  cornea  in  which  one  starts  by  virtually 
peeling  it  away.  The  operation  is  not  advised  in  active  corneal 
infiltrations,  but  only  in  persistent  corneal  scars. 

It  is  a  delicate  and  difficult  procedure  which  only  the  skilled 
surgeon  should  attempt.  In  selected  cases,  visual  and  cosmetic 
results  are  obtained  which  no  other  methods  within  our  present 
knowledge  can  supply. 

In  the  discussion  it  was  suggested  that  the  surgical  procedure 
advocated  by  Dr.  Wiener  might  change  the  thickness  of  the  cornea 
to  such  a  degree  that  a  very  annoying  irregular  astigmatism  might 
possibly  result.  The  members  thought  that  the  procedure  could 
hardly  commend  itself  at  the  present  time  to  ophthalmic  surgeons. 
The  work  done,  however,  by  Dr.  Wiener,  they  considered  a  valuable 
contribution  to  the  subject,  and  hoped  that  from  it  would  come 
results  of  permanent  value. 

CORNEAL  CAUTERY. 

Cauterization  in  some  form  or  another  for  the  treatment  of 
aft'ections  of  the  eye  has  so  wide  a  range  of  em|)loymenl  and,  as  a 
surgical  measure,  its  application  in  most  instances  is  so  similar,  that 
opportunity  wull  be  here  taken,  once  for  all,  to  say  a  few  words  rel- 
ative to  its  use  in  "eneral  as  well  as  to  that  in  connection  with  the 


386  OPERATIONS  UPON  THE  GLOBE 

cornea.  For  the  rest,  it  will  be  treated  of  under  the  different 
headings  wherever  it  finds  a  place. 

One  distinguishes  three  kinds  of  cautery,  viz.,  i.  the  chemic; 
2.  the  thermic,  and  3.  the  electric.  The  first  includes  those  sub- 
stances which,  brought  in  contact  with  the  tissues,  cause  an  eschar 
by  various  forms  of  chemical  action,  such  as  nitrate  of  silver,  for 
example.  Their  modes  of  application  are  described  in  the  chapter 
on  that  subject.  The  other  two  refer  to  those  where  heat  alone  is 
the  agent  which  jjroduces  the  decomposition  and  are  identical  in 
their  effect,  the  only  difference  being  as  to  the  manner  in  which  the 
heat  is  generated.  The  second  kind  is  usually  spoken  of  as  the 
actual  cautery,  and  the  third  as  the  galvano-cautery.  The  thermic 
cautery  has  been  an  adjunct  to  surgery  since  the  earliest  days  of 
medicine,  and  the  instrument  to  receive  and  apply  the  heat  has  been 
made  of  a  variety  of  materials.  Its  best  modern  representative  is  a 
platinum  wire  of  suitable  dimensions  and  shape  of  tip,  supplied 
with  a  handle  of  wood  or  other  non-conductor  of  heat.  In  an 
emergency  one  can  easily  improvise  such  a  cautery  from  a  bit  of 
wire  or  other  small  metal  implement.  The  best  means  of  heating 
it  are  the  flame  of  a  spirit  lamp  or  that  of  a  Bunsen  burner. 
"Cherry-red"  is  the  term  used  to  denote  the  degree  of  heat  which  is 
most  serviceable. 

The  Paquelin  appliance  is  also  a  handy  form  of  actual  cautery. 

As  concerns  the  electric  cautery,  since  its  introduction  by  Legroux^ 
it  has  largely  supplanted  the  other  two  in  the  hands  of  the  ophthalmic 
surgeon,  partly  because  of  the  greater  convenience.  A  small  storage 
battery  weighing  6  or  8  pounds  will  supply  an  ample  current  for 
many  operations.  Moreover,  seeing  that  the  home  of  the  oculist  is 
in  the  city,  he  can  always  have  access  to  the  street  currents,  which 
he  converts  to  this  use  either  by  means  of  a  transformer  or  of  a 
]jcrmanent  l)altery  and  rheostat.  Even  the  electrodes,  handles 
and  i)lalinum  ti])s  can  be  interchangeable  between  the  portable  and 
the  stationary  apparatus.  The  handle  and  wires  should  be  as  light 
as  possible,  and  the  button  for  making  and  breaking  the  current 
should  be  easily  manipulated  by  the  tip  of  the  forefinger  (Fig.  242). 
The  form  of  the  ])oints  is  a  matter  of  individual  preference.  Per- 
ha])S  the  Ijcst  ada|)te(l  lo  all-around  work  is  the  simple,  almost  closed 
loop  of  rcnind  or  slightly  flattened  wire,  though  the  olive  tip  is  excel- 
lent in  many  cases  (Fig.  243). 

>  Ann.  (I'oculist.  t.  8i,  p.  i8i,  1879. 


CORNEAL    CAUTERY 


387 


The  cleclro-caulcry  has  enjoyed  a  deserxed  det^rec  of  ])0|)uhirily 
in  the  Irealmenl  of  corneal  ulcers,  but  the  necessary  accessory 
eciuipment  for  its  use  is  frequently  not  available  when  it  is  most 
needed  and  it  is  always  open  to  the  objection  of  a  clumsy  handle 
and  difficult  regulation  of  the  current  so  as  to  produce  the  desired 
amount  of  heat.  Tlie  demand  for  a  sim])le,  effecti\-e,  and  ever-ready 
instrument  lias  ])roduced  Wordsworth's  cautery  (Fig.  244),  consisting 
of  the  regulation  instrument  handle  and  shank,  on  the  end  of  which 
is  a  copper  bulb  about  five  millimeters  in  diameter.  The  end  of 
the  shank  is  bent  at  an  obtuse  angle  so  as  to  allow  a  "ood  view  of 


I-"iG.  242. — Klectric  cauici 


Tile  conductors  go  over  operator's  shoulder. 


the  field  of  operation.  One  side  of  this  copper  bulb  is  drawn  out 
into  a  blunt  protuberance  for  use  in  the  cauterization  of  compara- 
tively large  surfaces,  while  at  another  point  on  the  bulb  is  attached 
a  delicate,  short  platinum  rod  for  use  on  small  surfaces.  The  bulb 
and  point  will  remain  sufficiently  hot  to  cauterize  for  several  min- 
utes after  being  heated  to  a  cherry-red  over  a  flame. 

To  Make  the  Cautery.— The  eye  is  prepared  and  anesthetized. 
The  speculum  is  put  in  and  the  globe  held  by  fixation  forceps. 
Having  seen  to  it  that  the  apparatus  is  in  working  order,  an  assis- 
tant supports  the  electrodes  while  the  surgeon  applies  the  tip.  Some 
prefer  to  lay  the  cold  tip  on  and  heat  it  m  situ.     Seeing,  however, 


388 


OPERATIONS    UPON    THE    GLOBE 


that  the  performance  should  be  a  mere  touch,  it  would  seem  that 
greater  precision  can  be  attained  by  holding  the  wire  close  to  the 
place  to  be  burned,  heating  it  to  the  right  color,  then  deftly  making 
the  contact.  If  the  tip  is  allowed  to  become  white-hot  (incandes- 
cent) its  energy  is  too  great,  and  besides,  the  light  startles  the  pa- 
tient.    The  touch  must  be  particularly  quick  as  regards  the  cornea, 

lest  steam   be   generated  in  the 
II  0  i?         ^       ""^Ni       aqueous.     It  is  much   better  to 

"  'i  "  ^       make  several  brief  applications 

than  attempt  too  much  with  one. 
Since    the    year    1873,    when 
Martinache,    of    San  Francisco, 
first  called   attention  to  its  vir- 
tues in  the  treatment  of  ulcers  of 
the  cornea,''-  the  cautery  has  come 
to  be  a  standard  remedy  for  all 
such  infectious   diseases  as  ser- 
fascicular,   annular,   dendritic  and  rodent  ulcers,  ulcerated 
wounds,  and  the  ulceration  incident  to  purulent  ophthalmia. 

In  addition  to  the  rules  governing  the  general  method  of  ocular 
cautery  just  given,  there  are  a  few  points  relating  to  corneal  cautery 
in  particular  that  it  were  well  to  mention.  If,  for  instance,  the 
ulcer  is  filled  with  curdled  pus  or  other  debris,  it  had  better  be  cleaned 
out  beforehand,  as  otherwise  the  operation  would  be  cluttered. 
Then,  if  a  drop  of  a  1%  solution  of  fluorescin  is  put  on  at  the  cornea, 
it  will  materially  help  one  to  distinguish  the  diseased  tissue  from  the 


2  3  4 

Fig.  243. — Cauterj-  tips. 


pent. 


Fig.  244. — Wordsworth-Todd  cautery. 


sound,  for  the  resulting  green  tint  will  not  only  show  the  lateral 
dimensions  of  the  ulcer  and  its  zone  of  infiltration,  but  also  their 
depth.  Czermak  recommends  touching  first  the  infiltrated  portion, 
making  a  series  of  small  burns  close  together,  and,  lastly,  the  center 
or  ulcer  itself,  the  last  either  by  the  small  points  or  by  a  somewhat 
larger  tip. 

Descemet's  membrane  should  be  spared  whenever  ])ossible.  It 
is  the  great  safeguard  of  Ihc  anterior  chamber.     Not  to  wound  it 

*  Pacific  Med.  and  Sur.  Journal,  Nov.,  1S73,  p.  294. 


INCISIONS    OF    THE    CORNEA  389 

when  the  ulcer  is  (Iccp  rc(|iiircs  great  dclicac}-  in  iKindlinLi;  the  lip. 
To  puncture  it  with  the  cautery  also  increases  the  risk  of  comjjlica- 
tions.  If  hypopyon,  which  ordinarily  can  be  i<^nored,  should  be 
present,  it  would  obstruct  the  perforation  and  ])re\ent  healin,<,^ 
The  eye  is  bandau;ed  after  the  operation  and  the  ])atient  kept  quiet. 
If  necessary  the  cautery  may  be  repeated. 

Another  form  of  corneal  ulcer  in  which  cautery  gives  most  gratifying 
results  is  the  narrow,  deep,  round,  central  one,  especially  when  this 
is  complicated  by  a  tiny  hernia  of  Descemet's  membrane.  When 
these  conditions  are  present  there  is,  often  apparently,  no  attempt 
at  spontaneous  healing.  I  liave  seen  such  cases  that  remained 
unaltered  for  months.  It  might  be  that  the  subject  was  young — as  they 
mostly  are — in  perfect  health,  and  receiving  every  other  appropriate 
form  of  treatment  for  the  eye,  even  to  the  pressure  bandage.  If 
any  change  occurred,  it  was  a  slow  one  for  the  worse.  This  was 
probably  from  pressure  of  the  protruding  membrane  on  the  tissue 
which  surrounds  it,  for  there  is  always  a  narrow  ring  of  gray  next 
the  hernia  that,  I  take  it,  indicates  a  mild  form  of  pressure  necrosis. 
One  or,  at  most,  two,  applications  of  the  galvano-cautery  will  effect 
a  speedy  cure.  Of  course,  in  this  instance,  Descemet's  membrane 
is  instantly  perforated  and  the  aqueous  spurts,  but,  owing  to  the 
absence  of  infection,  and  to  the  small  size,  and  position  of  the 
opening,  no  trouble  with  the  iris  ensues. 

Incisions  of  the  Cornea;  Paracentesis.  Function.  The 
number  of  indications  for  opening  the  anterior  chamber  that  have, 
first  and  last,  been  supposed  to  exist,  is  infinite.  In  truth  it  has, 
perhaps,  a  broader  field  of  alleged  utility  than  any  other  opera- 
tion that  is  made  upon  the  eye.  The  following  arc  some  modern 
applications: 

I.  In  Acute  Glaucoma,  whether  (a)  Idiopathic  or  (h)  secondary. 

a.  Given,  a  case  of  acute  glaucoma,  with  great  pain,  hyperemia, 
chemosis,  etc.,  and  it  is  not  practicable  to  give  a  general  anesthetic 
for  iridectomy.  It  is  well  known  that  cocain  has  no  effect  in  such 
cases,  yet  it  would  be  possible  to  make  a  simple  incision  at  the  base 
of  the  cornea  with  far  less  additional  suffering  on  the  part  of  the 
patient  than  to  go  ahead  with  the  iridectomy.  Having  relieved  the 
tension,  the  iridectomy,  if  still  necessary,  could  be  made  after  a  few 
days  under  cocain.  Moreover,  the  chances  of  loss  of  vitreous  and  of 
choroidal  hemorrhage  would  be  lessened  by  the  preliminary  incision. 

b.  In  acute  secondary  glaucoma,  such  as  that  from  the  swollen 


39°  OPERATIONS  UPON  THE  GLOBE 

lens  after  discission,  and  after  accidental  traumatism,  paracentesis 
is  imperative.  Under  these  conditions  the  procedure  is  usually 
accompanied  by  the  extraction  of  lens  substance.  I  have  had 
occasion  to  make  the  operation  in  fulminating  glaucoma  due  to 
dislocation  of  the  lens  into  the  anterior  chamber,  not  daring,  for 
the  moment,  to  attempt  extraction. 

2.  In  certain  cases  of  blood  in  the  anterior  chamber.  Ordinarily 
these  are  let  alone,  and  the  blood  is  promptly  absorbed.  If,  on  the 
contrary,  it  remains  for  5  to  7  days  without  appreciably  lessening 
in  quantity,  it  would  better  be  got  rid  of,  as  it  may  lead  to  the  so- 
called  spongy  iritis  or  organized  clot  and  other  dangers.  When 
present  as  the  result  of  an  injury,  the  blood  could  cause  a  foreign 
body  within  the  eye  to  be  overlooked.  Haab  mentions  the  pos- 
sibility of  a  hyphema  occurring  and  obstructing  the  pupil  in  a  case 
where  one  is  interested  in  ophthalmoscopic  observations,  as,  for 
instance,  the  de\-elo])ment  of  a  neoplasm. 

3.  In  Iritis  and  Iridocyclitis. — At  the  height  of  the  inllam- 
matory  process  there  often  comes  a  time  when,  because  of  the  hyper- 
emia, etc.,  the  iris  and  the  ciliary  muscle  cannot  be  made  to  respond 
to  the  mydriatics  and  cycloplegics  employed,  nor  do  soothing  reme- 
dies serve  to  relieve  the  severe  pain  in  and  about  the  eye.  As  was 
pointed  out  by  Abadie,i  free  punction  of  the  cornea  makes  the  eye 
more  responsive  to  treatment  and  the  patient  more  comfortable. 
Under  these  conditions  the  operation  would  need  to  be  performed 
under  narcosis.  There  is  another  class  of  cases  of  uveitis,  mostly 
chronic,  characterized  by  descemetitis,  increased  depth  of  anterior 
chamber,  cloudiness  of  vitreous,  recurrent  intraoculariiemorrhages 
(or  not),  and,  rarely,  notable  disproportion  between  the  amblyopia 
and  any  apparent  cause  for  it.  These,  too,  are  sometimes  helped 
by  ])aracentesis;  and,  as  they  are  among  the  most  tedious  and  trying 
of  all  our  charges,  and  the  operation  is,  to  say  the  least,  harmless, 
one  is  justified  in  trying  it. 

4.  In  ulceration  of  the  cornea  that  threatens  to  ])crforate, 
wlielher  there  is  hypoj)yon  or  not.  Ai)r()i)os  of  tlie  last,  before 
the  time  when  the  jjrofession  had  learned  to  rely  upon  the  efficacy 
of  antiseptic  treatment  for  these  infectious  conditions,  it  was  the 
rule  to  make  paracentesis  in  cases  of  h\-])()p\()n.  Consecjucnlly, 
eye  after  eye  was  lost.  This  was  true  e\en  in  the  earlier  |)eriod  of 
anlise])tic   medicini',   when   the  case  was  haxing  this  treatment  in 

'  (iaz.  (k'S  lio])il;iu\,  p.   2i(),    1S74. 


PARACENTESIS    CORXE.^-:  391 

addition.  Al  ])rescnt,  eye  after  eye  is  saved  by  disre.«,'ardin,i<  the 
hypopyon,  using  copious  irrigation  with  mild  antiseptics,  atropin, 
and,  above  all,  the  roller  bandage.  Paracentesis  in  any  form, 
according  to  the  Saemiscli  or  otherwise,  has  largely  given  way  to  the 
non-operative  treatment. 

5.  In  Conical  Cornea. — (See  section  on  Kcratoconiis.) 

6.  In  Embolism  and  Thrombosis  of  the  Retinal  Vessels.— 
Paracentesis  of  the  cornea  has  been  suggested  as  an  adjunct  to 
massage.  One  would  hesitate  before  making  the  operation,  how- 
ever, in  cases  of  advanced  arteriosclerosis.  It  would  seem  from  the 
researches  of  Fuchs,i  relative  to  the  nature  of  panophthalmitis  and 
the  course  of  the  infection  therein,  that  paracentesis  may  fmd  an 
extension  of  its  sphere  in  helping  to  save  from  enucleation  some 
of  the  eyes  thus  afflicted. 

Von  Graefe,-  proposed  punction  of  the  anterior  chamber  in  glau- 
coma simplex,  as  a  sort  of  guide  as  to  whether  or  not  an  iridectomy 
would  prove  beneficial.  One  is  often  put  in  a  quandary  when 
dealing  with  this  disease.  For  example,  in  spite  of  other  means 
of  treatment  the  sight  is  fast  going  and  the  fields  rapidly  dimin- 
ishing, yet  one  shrinks  from  an  iridectomy,  and  posterior  sclerotomy 
is  out  of  the  question.  As  a  tentative  measure,  one  may  make  para- 
centesis. If  the  symptoms  improve  for  a  time,  one  is  encouraged 
to  essay  the  excision  of  iris. 

The  Operation.— Narcosis  is  required  only  for  highly  inllamed 
and  sensitive  eyes,  especially  when  the  patient  is  shattered  from 
suft'ering,  and  for  small  children.  Where  there  is  much  softening 
of  the  cornea  or  tremendously  high  tension,  conditions  that  would 
make  squeezing  of  the  eye  dangerous,  the  blepharostat  would  better 
be  omitted  and  the  lids  held  apart  by  an  aid  with  retractor  or  fingers. 
The  best  form  of  keratome  is  a  small  iridectomy  knife,  except  there 
be  extreme  shallowness  or  obliteration  of  the  anterior  chamber, 
when  a  narrow  Graefe  cataract  knife  is  preferable.  The  incision 
should  be  sufficiently  peripheral  to  lie  within  the  vascular  zone  of 
the  cornea,  but  its  position  with  regard  to  the  circumference  will  be 
determined  by  circumstances.  When  blood  or  pus  is  to  be  evacuated, 
the  proper  point  is  downward.  In  other  cases,  as  in  glaucoma 
from  a  swollen  lens,  when  it  is  possible  a  portion  of  the  iris  will 
have  to  be  incised  upward,  and  so  on. 

1  Arch.  f.  Augenh.,  Iviii,  3,  S.  391. 
*  A.  F.  O.,  XV,  3,  211. 


392  OPERATIONS  UPON  THE  GLOBE 

The  globe  is  steadied  by  ilxation  forceps,  the  point  of  the  keratome 
is  made  to  enter  the  anterior  chamber  just  as  in  the  incision  for 
iridectomy.  When  tlie  bhide  has  been  pushed  far  enough,  the 
handle  is  tilted  further  backward  to  avoid  wounding  the  lens  during 
the  escape  of  aqueous,  and  tlien  turned  slowly  to  one  side  so  that 
the  knife  will  pry  open  the  cut  and  drain  the  anterior  chamber. 
Just  here  is  when  the  patient  is  apt  to  feel  the  greatest  pain,  sup- 
posedly from  the  contact  of  the  sensitive  iris  with  the  cornea,  and  is 
liable  to  squeeze  or  move  the  head.  It  is  for  this  reason  and  also 
to  prevent  prolapse  of  the  iris,  that  the  aqueous  must  not  be  allowed 
to  gush  out  suddenly.  The  knife  is  slowly  withdrawn,  if  need  be 
extending  the  incision  in  its  exit,  as  in  iridectomy.  If  the  Graefe 
knife  is  chosen,  the  incision  is  made  by  puncture  and  counter- 
puncture,  as  in  extraction,  though,  of  course,  its  extent  is  much  less. 
The  section  is  finished  slowly.  After  this  the  spatula  may  be  used 
to  pry  open  the  wound  or,  at  least,  to  depress  its  posterior  lip.  If 
blood  or  pus  is  to  be  evacuated,  it  may  be  coagulated  and  refuse  to 
come  out  wdth  the  aqueous.  In  this  event  an  injection  of  i%  warm 
salt  solution  by  means  of  one  of  the  syringes  for  lavage  of  the  anterior 
chamber  may  be  used  to  w^ash  out  the  clot  or  curd.  If  the  iris 
escapes  in  spite  of  proper  care  in  making  the  incision,  it  can  usually 
be  replaced  with  the  spatula.  If  not,  the  prolapse  must  be  excised. 
The  eye  is  bandaged  in  the  regulation  way. 

A  distinctive  method  of  paracentesis  is  the  incision  of  SacmiscJi,'^ 
and  one  that  has  been  extensively  employed  in  the  different  infectious 
ulcers  of  the  cornea.  The  original  mode  was  to  make  the  incision 
as  nearly  as  possible  in  the  center  of  the  ulcer.  Alfred  Graefe  and 
Meyhofer  taught  to  make  the  cut  as  a  tangent  to  the  ulcer  and  thus 
slit  the  infiltrated  border,  and  that  in  the  direction  of  its  greatest 
progress.  Saemisch  also  came  to  make  it  somewhat  similarly. 
Since  part  of  the  object  of  the  incision  was  to  drain  and  relax  the 
infiltrated  tissue,  as  in  orbital  phlegmon,  this  would  seem  ralicmal. 
A  narrow  Graefe  knife  is  used;  the  blade  is  entered,  edge  forward,  at 
one  extremity  of  the  affected  area,  and  brought  out  at  the  other 
extremity,  in  its  passage  being  made  to  open  the  anterior  chamber; 
i.e.,  l)y  puncture  and  counlcr-])uncture.  The  incision  is  reopened 
daily  by  a  small  probe  or  prol)c  ])ointed  lacrimal  knife  till  the 
ulcer  is  no  longer  a  menace.  The  constant  leakage  of  aqueous  is 
believed   to   prevent   infection   of  the    deeper  parts    of    the    eye. 

1  Ulcus  Serpens  Cornea  und  seine  Behandlung,  Bonn,  1S70. 


MASSAGE    OF    THE    GLOBE  393 

Manifestly,  the  same  precautions  must  be  taken  against  squeezing 
out  of  the  crystalline,  etc.,  as  in  other  forms  of  paracentesis.  The 
operation  is  difficult  with  the  Gracfe  knife  in  certain  meridians 
upon  deeply  set  eyes,  a  difficulty  that  can  be  overcome  by  the  use  of 
a  small  sickle-shaped  blade. 

Anterior  synechia,  leiicoma  adherens,  and  glaucoma,  the  natural 
sequels  of  septic  processes  in  the  cornea,  not  to  mention  panoph- 
thalmitis, arc  more  frequent  after  paracentesis  of  any  kind  has  been 
resorted  to  in  the  treatment  of  kerato-hypopyon. 

Paracentesis  and  Massage  in  Glaucoma.— In  cases  of  chronic 
or  intermittent  or  irritative  glaucoma — in  short,  in  any  but  the 
acute  idiopathic  variety— these  are  therapeutic  measures  that 
cannot  be  too  strongly  recommended.  They  are  harmless  and  cause 
the  patient  little  inconvenience,  yet  often  effective  in  the  highest 
degree.  The  paracentesis  should  be  thorough  and  very  slowly 
made.  Within  from  6  to  12  hours  afterward  the  eye  is  washed 
outwardly  with  warm  sublimate  solution,  the  contents  of  the 
Meibomian  canals  are  greatly  expressed,  the  eye  and  the  entire 
conjunctival  sac  are  copiously  irrigated  with  warm  boric  acid  solu- 
tion, and  a  systematic  course  of  massage  is  begun.  This  may 
be  either  direct,  i.e.,  by  a  smooth  instrument,  such  as  a  glass  rod 
with  rounded  end,  applied  immediately  to  the  globe;  or  indirect, 
i.e.,  by  the  fingers  applied  exterior  to  the  lids,  the  mode  accredited 
to  Pagenstecher.  I  prefer  the  last.  The  massage  may  also  be 
either  plain  or  medicamentous.  The  use  of  myotics  in  conjunction 
with  the  massage  is  most  always  indicated.  These  can  be  in  the 
form  of  solution  or  ointment — simple  or  combined.  The  ointment 
is  usually  preferable  as  it  clings  more  tenaciously  to  the  parts 
chiefly  concerned,  and,  besides,  facilitates  the  massage  as  a  lubricant. 
Simple  pilocarpin  muriate  or  eserin  or  both  together  or,  to  what  is 
probably  better,  these  two  combined  with  cocain.  The  latter  is 
the  pek  so  warmly  commended  by  Wicherkiewicz,  who,  by  the  way, 
has  been  one  of  the  foremost  advocates  of  this  kind  of  massage. 
The  author  has  of  late  used  vnth  apparently  good  results  a  mixture 
of  eserin,  cocain  and  dionin. 

Modus  Operandi  of  Massage.— The  same  rules  here  given  are 
applicable  to  ocular  massage  in  general.  Hands  and  eyes  are  care- 
fully prepared.  The  patient  sits  facing  the  operator.  The  work 
is  done  with  the  thumb  or  with  the  first  finger,  which  is  clad  in  a 
delicate  rubber  cot.     jSIassage  of  any  particular  part  of  the  globe, 


394  OPERATIONS  UPON  THE  GLOBE 

except  of  the  cornea,  is  made  witli  the  ])atient  lookin,^  in  the  opposite 
direction.  Thus,  for  the  u])i)er  ec^uatorial  region  the  eyes  are 
rotated  far  downward,  etc.  By  noting  the  position  of  the  other 
eye  one  knows  what  part  is  being  rubbed.  The  upper  lid  is  utilized 
for  the  upper  half,  or  rather  quadrant,  of  the  bulbus,  and  the  lower 
for  the  rest.  First,  circular  movements  are  made,  say  in  the  direction 
of  the  liands  of  a  clock.  Second,  this  is  reversed.  Third,  move- 
ments in  straight  lines  across,  up  and  down,  and  diagonally.  Fourth 
—  and  this  is  an  important  movement— by  backward  strokes, 
following  the  meridians  of  the  globe.  These  are  repeated,  in  regular 
sequence,  over  and  over.  The  degree  of  pressure  exerted  may  vary 
from  very  light  to  pretty  firm,  owing  to  the  needs  of  the  case,  and 
in  accordance  with  the  judgment  of  the  masseur.  The  intervals 
between  sittings  are  from  a  few  hours  to  an  entire  day,  as  the  case 
demands.  The  duration  of  the  massage  is  from  two  to  four  minutes 
for  a  single  eye.  By  covering  each  thumb  with  a  cot,  both  eyes 
can  be  done  simultaneously.  Anointing  of  the  lids  or  the  thumbs 
is  inadvisable;  though  sterile  vaselin  or  other  ointment  or  i%  salt 
or  4%  boric  acid  or  other  solution  should  be  put  into  the  conjunctival 
sac.  If  ointment  is  employed,  one  application  per  sitting  is  sufficient ; 
if  an  aqueous  solution,  two  or  more  instillations  are  made.  Ocular 
massage,  intelligently  practised,  is  a  most  valuable  adjunct  in  the 
treatment  of  most  affections  of  the  eye.  It  is  peculiarly  precious 
in  diseases  dependent  upon  degenerative  changes  in  the  circulatory 
apparatus,  like  glaucoma,  the  so-called  albuminuric  retinitis, 
arterial  and  venous  thrombosis  of  the  retina,  intraocular  hemor- 
rhage, and  embolism.^ 

Paracentesis  by  Galvano-puncture  of  the  Anterior  Chamber. 
— Haberkamp-  has  sought  a  measure  which  would  be  practicable 
without  preparation  and  which  might  be  done  in  a  consultation 
room  or  at  the  home  of  the  i)atienl.  While  he  claims  no  originality 
in  the  procedure  he  proposes,  he  has  been  unable  to  find  it  mentioned 
in  the  literature.  The  method  is  a  paracentesis  by  galvano-puncture 
of  the  anterior  cliamber  the  healing  of  tlie  i)uncture  being  slow, 
a  ])r()l()nged  effect  is  had,  greater  than  would  be  the  case  from  an 
onh'nary  paracentesis.  Haberkamj)  reports  two  cases  treated  by 
this  method.     'JMie  first  case  was  cured;  in  the  second  the  patient 

1  Bicrruiii,  of  ("uiu'iiIki-ch,  vrry  stroiiKlN'  rcconiiiu'iids  iirossion  massage, 
over'the  center  of  tlii'  rornoa  only  after  paracentesis  and  iridectomy  for 
chronic  Kl:itic<)ma.—A'0/7/j.  Provinc,  March,  1909. 

2  La  Ciinique  Ophtahiiologique,  July  10,  1905. 


CONICAL    CORNEA  395 

was  blind  from  fulminating  i^laucoma,  suffered  agonizin,^  ])ain,  and 
enucleation  was  at  first  deemed  essential;  galvano-puncturc  stopped 
the  pain  and  the  necessity  of  removing  the  eye  was  done  away  with. 

This,  in  llie  opinion  of  the  present  writer,  would  be  a  delicate 
undertaking  at  the  hands  of  one  not  skilled  in  the  use  of  the  cautery; 
as  overheating  of  the  acjucous,  with  consequent  injury  to  the  iris 
and  the  crystalline,  could  easily  be  brought  about. 

Conical  Cornea;  Keratoconus;  Staphyloma  Pellucidnm. — 
The  first  two  terms  describe  the  abnormality  better  than  does  the 
third,  since  it  is  the  shape  of  the  cornea  that  gives  name  to  the  defect 
without  any  special  reference  to  its  transparency,  for  in  many 
instances  considerable  opacity  exists.  The  apex  of  the  cone 
is  seldom  at  the  center,  being  for  the  most  ])art  situated  below  the 
center.  Keratoconus  is  of  two  kinds — primary  or  idiopathic  and 
secondary.  The  first  is  peculiar  to  young  subjects,  beginning  about 
the  age  of  puberty,  and  gradually  increasing  till  well  into  adult  life. 
It  is  bilateral,  and  seen  oftener  in  females  than  in  males.  The 
second  is  the  result  of  disease  of  the  cornea,  with  consequent  stretch- 
ing and  thinning.  It  is  frequently  monolateral.  Either  kind  may 
lower  the  vision  almost  to  zero,  irrespective  of  any  opacity,  when 
surgical  intervention  becomes  urgent. 

Many  and  ^•aried  are  the  surgical  measures  that  have,  during  the 
last  century,  been  devised  relative  to  this  condition.  The  first 
were  directed  more  to  improvement  of  the  vision  than  to  the  re- 
duction of  the  cone.  Travers  and  Tyrrell,  for  instance,  in  the 
second  decade  of  the  i8th  century,  made  optical  iridectomy,  and 
later  Critchett  and  Bowman  attempted  to  substitute  the  danger- 
ous operation  of  iridodesis.  The  first  to  institute  a  procedure  for 
the  actual  cure  of  the  deformity  was  Fario,i  in  1839.  He  re- 
moved a  wedge-shaped  piece  from  the  summit  of  the  cone,  dressed  the 
eye,  and  allowed  the  wound  to  heal  without  suturing,  and  declared 
himself  satisfied  with  the  results.  Sichel  and  von  Graefe,  near  the 
middle  of  the  19th  century,  sliced  off  the  tip  of  the  cone,  preserving 
Descemet's  membrane,  then,  after  a  day  or  so,  touched  the  spot 
with  mitigated  stick.  The  cautery  was  regularly  applied  until 
healing  occurred.  After  this  the  tip  of  the  cone  was  punctured, 
the  aqueous  drained,  and  attempts  made  to  maintain  the  fistula 
by  subsequent  punctures,  with  the  object  of  still  further  flattening 
the   cornea.     If  necessary,    an   optical   iridectomy   completed   the 

1  Mem.  delta  Med.  contemp.,  1839. 


396  OPERATIONS  UPOX  THE  GLOBE 

surgical  treatment.  Bowman,  in  1869,  removed  the  whole  thickness 
of  the  apex  with  a  trephine  of  his  own  invention.  He  later  modified 
the  measure  by  leaving  the  posterior  layer.  Several  days  thereafter, 
the  floor  of  the  excavation  was  perforated,  and  regularly  reopened 
for  a  period  of  two  or  three  weeks.  Such  a  procedure  could  not 
be  applicable  where  the  usual  amount  of  thinning  exists  at  the 
summit.  De  Wecker  and  Warlomont  also  had  their  trephines. 
Bader^  removed  an  oval  flap  from  the  apex,  now  stitching  the  open- 
ing with  fine  silk  or  silver  wire,  again  leaving  it  to  close  of  itself. 
All  of  these  operative  processes,  while  credited  with  a  modicum  of 
success,  were,  on  the  whole,  both  unsatisfactory  and  hazardous — ■ 
the  last,  mainly  because  of  the  great  reaction,  of  infection,  and 
of  iris  complications.  No  better  results  followed  the  method  of 
excising  a  segment  from  the  base  of  the  cone,  tried  by  Quadri, 
Roosbroeck,  and  others.  Gayet,^  to  avoid  these  dangers,  practiced 
cautery  of  the  apex,  to  perforation.  Abadie,^  to  obviate  central 
opacity,  moved  the  cautery  from  the  apex  to  the  more  peripheral 
portions  of  the  zone,  respecting  the  posterior  layer.  Since  the 
introduction  of  the  thermic  (or  electric)  cautery  for  this  purpose, 
cauterization  of  the  apex  has  largely  taken  the  place  of  excision. 
The  difference  in  the  size  of  the  resulting  scar,  after  excision  and 
cautery,  is  very  slight,  particularly  if  the  cautery  is,  as  it  should  be, 
limited  to  a  small  area.  One  beauty  of  the  cautery  is  that  it  is  its 
own  antiseptic.  Since  Tweedy's^  report,  the  weight  of  opinion  is 
largely  in  favor  of  cautery  ivith  as  against  that  without  perforation. 
Knapp^  indorses  perforation.  This  surgeon  has  had  made  a  special 
round  tip  for  burning  the  cone.  This  he  lays  on  cold  and  heats  till  it 
perforates.  He  gives  a  timely  caution  as  to  overheating  of  the 
aqueous,  consec^uently  of  the  lens  and  iris;  even  cites  a  case  in  which 
he  supposes  he  produced  a  cataract  in  this  way.  This  would  seem 
to  be  another  argument  in  favor  of  heating  the  tip  before  making 
the  contact. 

Kalt  iSoc.  fran{.  (Fopht.,  1899,  \).  423)  at  the  suggestion  of  A. 
Terson,  made  median  tarsorrhaphy,  after  the  manner  of  Panas, 
keeping  the  lids  closed  for  from  six  months  to  a  year,  and  found  it 
cffecti\c  for  the  moderate  degrees  of  conicity  when  early  api)lie(l. 

1  Lancet,  1S72. 

2  Lyon  mcdicale,  xxx,  1S79. 
sThbse  de  Guiot,  1887. 

*  Trans,  of  Oph.  Scy.  of  the  U.  K.,  Jan.  28,  1892. 

^  Norris  and  Oliver,  "  Diseases  of  the  Eye,"  p.  82  5,  1 898. 


CONICAL   CORNEA  397 

Accordin,^  to  recent  reports,  it  would  seem  that  conjunctiN-al 
keratoplasty,  as  an  auxiliary  to  the  cautery,  is  destined  to  pro\e  of 
vast  ser\ice  in  the  surgical  treatment  of  this  alTection.  As  examj^les 
the  methods  of  two  well-known  operators  will  he  cited.  The  first 
is  that  of  Gruncrt,  of  Bremen,  who  reports  having  treated  eleven 
eyes  of  eight  patients  by  it.  He  first  uses  an  electrode  with  a  flat 
tip.  Beginning  at  the  upper  limbus,  the  cornea  is  cauterized  for  a 
length  of  2  to  3  mm.,  the  burn  reaching  into  the  parenchyma;  then, 
with  the  finest  tip,  this  line  is  extended  into  an  ecjuilateral  triangle, 
one  apex  being  continued  as  a  fine  line  to  the  center  of  the  cone. 
Two  days  later  the  chief  operation  is  done  under  narcosis.  The 
slough  is  scraped  oft',  the  cornea  is  split,  along  the  middle  of  the 
burned  line,  from  the  center  to  the  limbus.  The  central  meridian 
of  the  cornea  is  then  covered  with  a  conjunctival  bridge  after  Kuhnt's 
method  (see  page  406).  Four  weeks  later  the  flap  is  transplanted 
back. 

Grunert  mentions  the  following  details:  The  pupil  must  be  con- 
tracted ad  minimum,  by  eserin,  before  the  beginning  of  the  chief 
operation.  After  careful  removal  of  the  slough  the  conjunctival 
bridge  is  formed,  preferably  from  the  external  scleral  conjunctiva. 
It  should  contain  as  little  subconjunctival  connective  tissue  as  possi- 
ble. It  should  be  laid  experimentally  over  the  perpendicular  merid- 
ian of  the  cornea,  the  sutures  put  in  and  tied,  to  see  if  it  lies  tense, 
and  covers  at  least  a  width  of  from  5  to  7  mm.  The  sutures  are  then 
loosened,  the  flap  put  aside,  and  the  cornea  slit.  The  point  of  a 
Graefe  knife  is  passed  i  mm.  below,  through  the  center  of  the  cone, 
the  sharp  edge  up,  as  in  slitting  an  abscess.  The  knife  point  is 
pushed  to  the  angle  of  the  anterior  chamber,  the  handle  elevated, 
and  the  exact  middle  of  the  burnt  line  is  slit  up  to  the  scleral  border. 
After  the  aqueous  humor  has  flowed  off  the  cone  collapses,  forming 
many  small  folds.  The  conjunctival  flap  is  now  laid  over  it  and  fixed 
with  sutures.  It  lies  loosely,  with  the  anterior  chamber  opened,  and 
becomes  tense  only  when  the  chamber  forms  again.  Later,  as  it 
contracts,  its  tension  increases,  and  is  exerted  upon  the  cone.  The 
patients  are  left  in  bed  for  six  to  eight  days  with  a  double  bandage. 
At  each  change  of  dressings  eserin  or  pilocarpin  is  instilled. 

When  the  sutures  do  not  cut  out  spontaneously  they  are  removed 
on  the  sixth  day.  The  lower  part  of  the  flap  retrogrades  slowly  to- 
ward the  side,  as  it  lies  on  intact  corneal  epithelium.  Four  weeks 
after  the  chief  operation  the  conjunctival  bridge  is  restored  to  its 


39o  OPERATIONS  UPON  THE  GLOBE 

original  bed,  leaving  the  small  portion  that  had  become  adherent 
to  the  denuded  surface  of  the  cornea.  In  some  cases  it  had 
become  atrophic,  so  that  a  transplanting  appeared  useless.  It 
then  was  simply  cut  away.  Four  weeks  later  the  part  of  the  flap 
covering  the  burn,  not  becoming  atrophic,  is  removed  or  trans- 
planted back, 

Golovine,  of  Moscow  (Translation  by  Fox  in  Ophthalmology, 
April,  191 2,  in  a  case  of  idiopathic  keratoconus,  cauterized  the 
summit  of  the  cone  by  means  of  a  fine  thermocautery  over  an  area 
3  mm.  in  diameter.  Although  the  cauterization  was  as  superficial 
as  possible,  it  was  seen  that  the  apex  was  so  thin  that  it  was  perforated 
and  the  anterior  chamber  emptied  itself.  Atropin,  zeroform,  and 
dressings  applied. 

During  the  next  ten  days  the  anterior  chamber  reappeared  and 
disappeared,  the  irritation  of  the  eye  increased  from  day  to  day,  a 
pericorneal  injection  menaced  the  entire  anterior  segment  of  the  eye, 
and  at  the  site  of  the  cauterization  one  saw  the  orifice  of  a  fistulous 
passage.  The  patient  suffered  only  when  the  anterior  chamber  had 
been  reformed;  on  the  contrary,  when  it  emptied  itself,  felt  himself 
relieved. 

Xeroform,  dressing,  eserin  (in  place  of  the  atropin  of  earlier  days). 

April  24.     Second  cauterization.     (The  first  was  April  12.) 

April  25.     The  eye  is  inflamed,  there  is  no  anterior  chamber. 

April  28.  Third  cauterization;  no  change,  excepting  a  slight 
edema  of  the  lids. 

May  3.  Conjunctival  autoplasty  of  the  wound  by  Reverdin's 
method,  dressing,  eserin. 

May  4.  Again,  no  amelioration,  the  graft  has  fallen  off,  and  there 
is  no  anterior  chamber. 

May  5.  Conjunctival  transplantation  according  to  the  method 
of  Kuhnt.     (See  chapter  on  "Keratoplasty.") 

A  strip  of  the  external  segment  of  the  bulbar  conjunctiva  deli- 
cately raised  at  the  middle,  is  brought  directly  over  the  wound 
previously  revived  by  means  of  a  small  curette.  Maintained  at  its 
two  extremities  by  its  pedicles,  the  strip  is  fixed  to  the  conjunctiva 
at  the  level  of  the  limbus  by  a  certain  number  of  threads. 

May  6.  The  autojjlasty  has  a  good  a])})earance,  but  there  is  no 
anterior  chamber. 

May  8.     Reappearance  of  the  anterior  chamber. 

May  10.     The  anterior  chamber  is  deepened. 


CONICAL    CORNEA  399 

May  12.  Anterior  chamber  normal,  the  pupil  distint  lly  xisihlc 
The  stitches  removed. 

May  14.  Section  of  the  supcricjr  jx'diclc,  and  on  May  20,  of  the 
inferior  pedicle  of  the  tlaj). 

Toward  the  end  of  the  month  of  May  the  patient  left  the  clinif, 
havin.L!;  in  the  center  of  the  cornea  of  the  left  eye  a  perfectly  spherical 
conjunctival  graft,  4'mm.  wide  and  firmly  fixed.  As  medicament: 
one  drop  of  eserin  daily. 

Five  months  later  the  patient  was  again  examined.  A  central, 
round  leucoma,  3  mm.  in  diameter,  replacing  the  primitive  graft 
and  a  ])erfectly  spherical,  normal  cornea.  The  pupil  reacted 
to  light  and  there  were  no  synechia.  V=(with  —4  spherical,  4 
cyl.)  0.4. 

October  15.  An  optical  iridectomy  upward  and  inward.  Oper- 
ative procedure  normal.  The  patient  was  seen  again  in  May,  igii, 
that  is  to  say,  one  year  after  the  first  operation.  The  cornea  is  spher- 
ical, normal,  vision  =0.7  without  lenses.  He  later  continued  his 
studies  (being  a  medical  student)  and  was  able  to  make  delicate 
microscopic  investigations. 

Elschnig,'  of  Prag,  has  for  the  past  15  years  been  an  enthusiastic 
advocate  of  the  galvano-cautery  for  keratoconus.  He  believes  that 
one  of  the  essentials  of  success  is  the  prompt  vascularization  of 
the  cauterized  area,  which  increases  the  density  and  lessens  the 
extent  of  the  resulting  cicatrix,  and  causes  greater  flattening  of  the 
scar.  In  order  to  hasten  this  vascularization  he  connects  the  deep 
eschar  at  the  summit  by  a  more  superficial  one,  running  in  a  broad 
strip  to  the  nearest  portion  of  the  corneal  limbus.  Because  of  the 
eccentric  position  of  the  apex  in  most  cases,  neither  the  denser  scar 
nor  its  bridge-like  extension  interfere  with  vision  through  the 
normal  pupil.  If  it  should  so  happen  that  the  tip  of  the  cone  is 
central,  tlie  i)rofound  burn  is  placed  to  one  side  so  that  the  scar  will 
not  encroach  too  much  upon  the  pupil.  He  considers  subsequent 
iridectomy  unneccessary  or  harmful,  though  he  may  afterward 
tattoo  the  opacity  in  such  a  way  as  to  prevent  diffusion.  He  uses 
the  dull  red  heat.  These  measures,  if  not  more  potent  for  good  than 
the  older  ones,  have  at  least  been  less  productive  of  harm. 

The   author  believes   with    Panas    that,   all    things    considered, 
the  more  conservative  measures  are  the  best,  except  for  the  extreme 
cases.     These  consist   in   the   prolonged    use  of  myotics   and   the 
1  Wiener  klinische  Rundschau,  1904,  20. 


400  OPERATIONS  UPON  THE  GLOBE 

pressure  bandage,  as  advocated  by  Weber,  ^  and  Mohr.-  Continued 
pressure  alone  is  probably  the  most  efficacious  of  any  single  means. 
The  writer  had  occasion  a  short  time  since  to  cause  removal  of  the 
lenses  in  a  case  of  high  myopia  and  conicity  of  the  cornea  by  a 
series  of  discissions.  The  treatment  consisted  in  incising  the 
capsule  through  puncture  at  the  bass  of  the  cornea — done  with  a 
Graefe  knife,  the  use  of  atropin,  and  bandaging.  The  duration  of 
treatment  for  each  eye  was  about  six  months.  There  were  three 
discissions  in  each,  a  good  deal  of  reaction  following  the  second  and 
third.  The  ultimate  flattening  of  the  corneas  was  truly  remarkable. 
The  best  ^•ision  with  glasses  before  the  operations,  etc.,  was  20/70, 
both  eyes;  the  best  after  the  year's  treatment  20/30+  both.  Here 
the  annulment  of  the  myopia,  W'hich  had  been  26  and  24  diopters, 
would  account  for  most  of  the  added  sight,  but  I  attributed  much 
of  it  to  the  reduction  of  the  cones.  Certainly,  thorough  trial  of  the 
less  radical  measures  should  precede  any  operation  that  involves 
special  risk.  These  would  be,  prolonged  wearing  of  compressive 
bandage  (best  netting,  put  on  wet),  the  cotton  of  the  pad  being 
carefully  built  on,  first  tilling  in  the  depressions  in  the  lids  around 
the  globe,  and  the  dressing  renewed  daily,  when  2  drops  of  2% 
solution  of  the  nitrate  or  muriate  of  pilocarpin  are  instilled.  This 
kept  up  as  long  as  improvement  continues.  I  teach  the  mother  or 
other  member  of  the  family  how  to  apply  the  bandage,  and  it  is 
surprising  how  patiently,  constantly  and  for  how  long  a  time  -the 
patient  will  submit  to  the  process.  If  no  progress  is  made, 
repeated  paracentesis  of  the  cornea  is  subjoined,  to  which  might, 
as  an  ulterior  measure,  be  added  the  application  of  a  small  galvanic 
tip,  in  three  or  four  short  meridional  hnes,  near  the  base.  If  these 
measures  failed  of  material  improvement,  I  should  still  advise 
against  more  drastic  surgical  treatment  save  where  the  ectasia  is 
very  great  and  the  vision  very  poor,  so  poor,  indeed,  as  hardly  to  be 
called  useful.  True,  much  depends  upon  the  condition  of  the 
fellow  eye.  If  this  ])e  possessed  of  fair  sight,  one  may  venture 
further. 

Staphyloma  of  the  Cornea.  Anterior  Staphyloma. — By  this 
term  is  understood  those  forms  of  ectasia  of  the  cornea  which  de- 
velop in  consequence  of  disease,  such  as  ophthalmia  neonatorum, 
accidental  wounds,  as  from  the  blades  of  knives  and  scissors,  and 

»  A.  S.  O.,  x.xii,  No.  4,  p.  215,  1876. 
2  A.  S.  O.,  x.xiii,  No.  2,  p.  iSo,  1877. 


CONICAL   CORNEA  40I 

surgical  operations,  such  as  iridectomy  and  extraction.  The 
staphyloma  is  known  as  total  or  ])artial,  according  as  the  whole 
cornea  or  only  a  portion  of  it  is  involved  in  the  bulging.  Blindness 
is  a  necessary  accomplishment  of  the  total  form,  not  of  the  partial. 
The  surgery  of  total  staphyloma  dates  from  ancient  times.  The 
Greeks  and  Romans  as  early  as  the  Alexandrian  period  practised 
ligation  for  its  removal.  A  needle  and  thread  were  run  through  the 
center  of  the  base.  The  thread,  which  was  left  double,  after  being 
pulled  well  through,  was  cut  near  the  needle.  Of  the  two  threads 
thus  formed,  one  was  used  to  ligate  each  half  of  the  staphyloma, 
^tius,  early  in  the  Christian  era,  improved  upon  this  method  by 
employing  two  needles  put  through  the  base  at  right  angles  one  to  the 
other.  Thus,  when  the  double  threads  were  pulled  through  and  cut, 
four  ligatures  were  made,  one  for  each  quarter  of  the  tumor.  Am- 
brose Pare,  in  the  i6th  century,  in  case  of  a  staphyloma  that  pro- 
truded beyond  the  lids,  amputated  it  bodily.  Beer,  of  Vienna,  in 
1805,  gave  a  method  that,  under  the  name  of  abscission,  became 
classic.  By  means  of  his  triangular  cataract  knife  he  made  puncture 
and  counterpuncture  in  the  horizontal  meridian  at  the  base  of  the 
elongated  cornea,  directing  the  edge  of  the  blade  forward  and 
downward,  cutting  out  within  the  base  below,  then,  with  the  scis- 
sors, he  made  a  similar  incision  upward,  completing  the  abscission. 
Of  course,  the  lens  and  part  of  the  vitreous  often  escaped  by  the 
enormous  opening.  George  Critchett,^  of  London,  to  keep  back  the 
contents  of  the  globe  after  the  Beer  abscission,  first  inserted  threaded 
curved  needles,  convexity  backward,  from  above  downward  through 
the  ciliary  body,  about  3  mm.  apart,  left  them  projecting  from  the 
sclera  at  either  end  to  serve  as  bars  to  the  vitreous,  etc.,  while  the 
staphyloma  was  removed.  The  needles  were  then  passed  on 
through,  leaving  the  sutures  in  their  places,  the  last  being  tied  to 
close  the  wound.  Not  liking  the  idea  of  passing  needles  and 
threads  through  the  sclera,  and  especially  through  the  ciliary  region, 
Knapp,2  using  fine  curved  needles,  put  them  through  the  con- 
junctiva and  superficially  into  the  sclera,  as  show-n  in  Fig.  245. 
Beginning  just  external  to  the  vertical  meridian,  a  little  back  of  the 
base  of  the  cornea,  one  needle  was  put  through  the  conjunctiva  and 
quilted  for  a  distance  of  4  or  5  mm.  horizontally  outward,  brought 
out,  carried  below  the  cornea,  and  i)assed  in  the  same  way,  but  from 

1  Royal  L.  O.  H.  Reports,  vol.  iv,  p.  i,  1863. 

2  Archiv.  S.  Oph.,  Bd.  xiv,  i,  S.  273,  1868. 

26 


402 


OPERATIONS  UPON  THE  GLOBE 


without  inward.  The  thread  was  not  drawn  down  between  the 
two  points,  Init  left  stancHn,^  in  a  long  loop.  A  second  suture  was 
introduced  in  the  same  manner  internally.  The  Beer  abscission 
was  then  made,  the  two  loops  drawn  down  across  the  extremities 
of  the  wound,  and  the  opposite  ends  of  thread  tied.  Mrtually,  the 
two  threads  play  the  role  of  four  vertical  sutures.  De  \Vecker,i 
modified  Knapp's  procedure.  He  first  incised  the  conjunctiva  all 
around  the  base  of  the  incision,  dissected  it  back  somewhat,  and  put 
into  it  a  purse-string  suture;  abscised  the  corneal  ectasis  after  Beer, 
and  tightened  the  thread  drawing  the  conjunctiva  tightly  closed  over 

the  opening  in  the  globe.  De 
Wecker,  about  1883,  wisely  con- 
cluded to  make  complete  exen- 
teration of  the  globe  before 
closing  the  wound. 

Kiichler,-  of  Darmstadt,  sim- 
ply incised  the  staphyloma  hori- 
'zontally,  straight  through  its 
center,  after  the  manner  of  his 
Querschnitt  for  extraction,  re- 
moved the  lens,  and  allowed  the 
wound  to  cicatrize. 

Such  is  a  brief  history  of  the 
!(,.  24,v— vnapp.  development  of  the  operation  of 

abscission,  for  total  staphyloma  of  the  cornea,  a  measure  that  is  now, 
happily,  fast  becoming  obsolete.  Ophthalmic  surgeons  are  be- 
ginning to  realize  the  folly  of  a  procedure  that  only  makes  the 
operated  eye  a  greater  menace  to  its  fellow.  That  is  to  say,  the 
portion  which  is  admitted  to  be  the  source  of  sympathetic  inflam- 
mation, viz.,  the  uvea,  was  not  only  left  behind,  but  left  in  condition 
more  potent  for  mischief;  that  the  stump  is  unsightly  without  a 
prothesis,  yet  that  the  latter  is  sui)])orted  even  better  after  exentera- 
tion; that  there  are  three  objects  for  removing  a  total  staphyloma 
— to  correct  a  deformity,  to  prevent  sympathetic  inflammation,  and 
to  make  a  suitable  stump  over  which  to  wear  an  artificial  eye.  The 
old  method  fulfllled  only  the  minor  indications.  Of  course,  where 
both  eyes  are  blind  it  does  not  matter.  Wlien  the  eye  is  highly 
glaucomatous  or  that  of  a  subject  well  along  in  years,  ex])ulsive 


'.\nii.  (!■ 
2  Ilcidrll 


cvsroii)  (  UAikix  403 

choroidal  hcmorrha,ti;c  is  apt  lo  follow  ahlalion.  (iradualiy,  iherc- 
forc,  the  o])eralion,  withoul  cxcnlcralion.  has  lost  favor,  and  the 
one  unlh  has  found  it.  Xolwithstandin,^  the  fad  that  a  nunil)er  of 
surgeons  still  resort  to  the  first  form,  the  writer  believes  that  it  has 
had  its  day,  and  deserves  no  better  fate. 

Partial  staphyloma,  or  cystoid  scar  of  the  cornea  may  be  any 
thing  from  (a)  a  tiny  bead  no  larger  than  a  pin-head  to  a  tumor  the 
size  of  a  pea,  centrally  located,  and  composed  only  of  Descemct's 
membrane,  translucent  or  whitish  in  color,  and  more  or  less  thick- 
ened; or  (/))  a  globular  mass  of  varying  si/e,  situated  somewhat  less 
centrally,  composed  ])artly  of  changed  iris  tissue,  and  dark  in  color 
in  proportion  to  the  amount  of  pigment  or  the  thinness  of  the  outer 
covering,  and  is  in  full  communication  with  the  anterior  chamber. 
Again  (c)  it  may  occupy  the  extreme  periphery,  where  it  is  made  up . 
in  great  part  of  the  iris,  is  of  many  sizes,  and  is  connected  with  the 
aqueous  chamber  only  by  a  fistulous  tunnel.  The  last  two  are 
prone  to  progressiveness,  often  reaching  enormous  proportions — the 
latter  especially;  eventually  dragging  in  the  ciliary  body  and  other 
parts  of  the  globe.  Hence,  it  is  of  the  greatest  importance  that 
surgical  measures  be  instituted  at  the  earliest  possible  moment. 

(a)  A  touch  of  the  heated  cautery  tip  or  a  simple  incision,  with 
proper  rest  and  bandaging  afterward,  is  usually  sufhcient  for  the 
smaller  kind.  A  very  few  will  be  found  of  sufficient  size  to  oblige  the 
cutting  out  of  an  ellii)tical  piece.  This  is  done  with  cataract  knife 
and  iris  scissors,  in  conjunction  with  a  conjunctival  covering. 

[b)  Glaucoma  is  a  frequent  attendant  of  the  second  variety. 
If  the  tumor  is  of  incipient  size  and  quite  recent,  amounting  to  a 
simple  hernia  of  the  iris,  one  may  be  able  to  mobilize  the  iris  with 
the  spatula,  then  draw  it  out  somewhat  with  iris  forceps,  and  snip  it 
off,  or  to  cause  its  disappearance  by  one  or  two  a])plications  of  the 
cautery.  Tf  the  tumor  is  larger,  particularly  if  the  intraocular 
tension  is  high,  an  iridectomy  will  be  required  in  connection  with 
cautery  or  incision  or  abscission,  whichever  of  the  three,  in  the 
judgment  of  the  operator,  is  called  for.  For  these  more  trouble- 
some cases  with  shallow  anterior  chambers,  a  very  narrow  Graefe 
knife,  one  that  has  been  reduced  by  many  sharpenings,  will  be  found 
invaluable  for  making  the  incision  to  get  at  the  iris;  a  pair  of  minia- 
ture forcejjs  scissors  will  sometimes  enable  one  to  excise  a  ])oriion 
where,  by  reason  of  its  union  with  tlie  cornea,  it  could  not  be 
drawn  out  bv  forceps  in  the  usual  wav.     How  much  benefit  is  de- 


404  OPERATIONS  UPON  THE  GLOBE 

rived  from  the  iridectomy  and  how  much  from  the  paracentesis 
and  bandaging,  it  were  im])ossible  to  say.  Xo  hxed  and  precise 
rules  can  be  given  for  the  manner  of  procedure  in  these  cases — 
the  conditions  are  too  variable. 

(c)  If  the  cystoid  scar  has  not  reached  proportions  too  consider- 
able, it  is  best  to  adopt  decisive  measures  while  it  is  yet  time.  The 
cyst-like  tumor  must  be  freely  opened  by  an  incision  with  a  Graefe 
knife,  all  of  the  included  iris  removed  that  seems  practicable,  and 
what  cannot  be  consistently  taken  away  disconnected  as  thoroughly 
as  possible  from  that  within  the  eye.  Having  cleaned  the  floor  of 
the  cyst,  the  fistula  is  sought  and  touched  with  the  cautery.  Bandag- 
ing and  rest  in  bed  for  four  or  five  days  complete  the  cure.  If  the 
ectasia  has  become  so  great  and  far-reaching  as  to  make  this  form 
of  treatment  inexpedient,  iridectomy,  light  cautery  of  the  most 
prominent  part  of  the  tumor,  the  instillation  of  myotics,  prolonged 
bandaging,  offer  perhaps  the  best  alternatives.  The  cautery  may 
be  repeated  as  many  times  as  it  would  seem  to  be  necessary,  and,  if 
done  so  lightly  as  not  to  cause  evacuation  of  the  aqueous,  it  were  well 
to  add  paracentesis  for  this  purpose.  The  walls  of  the  staphyloma 
are  commonly  of  extreme  thinness.  The  effect  of  cautery  is  not 
only  to  help  the  iridectomy,  the  paracentesis  and  the  bandaging  in 
bringing  about  flattening,  but  it  tends  to  cause  thickening  and 
strengthening  of  the  wall  through  the  building  up  of  connective 
tissue.  The  support  afforded  by  snug  bandaging,  if  continued  for 
weeks  or  months,  will  of  itself  cause  a  deposit  of  connective  tissue 
that  could  not  occur  if  the  eye  were  left  free.  Conjunctivo-kerato- 
plasty,  as  next  described,  is  a  valuable  adjunct  in  many  of  these  cases. 

KERATOPLASTY  AND  CORNEAL  GRAFTING. 

The  first  relates  to  conjunctival  keratoplasty. 

Conjunctivo-keratoplasty.— The  use  of  the  bulbar  conjunc- 
tiva, by  loosening  and  transposing  it,  as  a  means  of  preventing, 
protecting  and  healing  corneal  lesions,  is  probably  the  most  salutary, 
and  far  reaching  in  its  benefits,  of  all  the  more  recent  acquisitions  to 
ophthalmic  surgery.  It  was  only  in  1873  that  the  idea  was  first  put 
into  practice,  and  that  by  De  Wecker.  In  ablation  of  anterior 
staphyloma  he  loosened  the  conjunctiva  all  around  the  cornea,  back 
to  the  equator  of  the  globe,  put  in  a  purse-string  suture,  and  after 
the  excision  of  the  sta])hyloma,  closed  the  opening  by  drawing  the 


KERATOPLASTY 


405 


conjunctiva  over  it  {Annal.  d^oculisl.,  LXIX,  p.  51,  1873).  When 
he  feared  infection  after  extraction,  he  resorted  to  the  same  expedient. 
Three  years  later  appeared  reports  of  the  very  elaborate  work  of 
Scholer,  of  Berlin,  along  this  line,  which  appeared  both  in  the 
Jahresbericht  and  in  Die  Augenklinik  zu  Berlin,  for  the  year  1876. 
He  gave  further  observations  a  year  later  (Berliner  kl.  Woch.,  XLVI, 


W    fc 


Fig.  246. 


Fig.  247. 


1877).  Scholer  employed  both  conjunctival  grafts  and  sliding  and 
pedunculated  liaps,  and  for  such  diverse  lesions  of  the  cornea  as 
perforating  and  nonperforating  ulcers,  gaping  wounds,  with  or  with- 
out iris  prolapse,  fistulas,  cystoid  scars,  and  beginning  staphyloma. 
Strange  to  say,  no  one  else  took  the  matter  up  until  1884,  when  Kuhnt, 
unapprised  of  Scholer' s  work,  conceived  of  similar  measures.     These 


Fig.  249. 


he  soon  elaborated  upon,  widening  their  scope,  and  refining  their 
technic,  to  such  a  degree  that  his  name  has  become  identified  with 
this  branch  of  surgery. 

The  methods  as  practised  at  present  are  by  either  sliding  large 
sections  of  conjunctiva  over  more  or  less  extensive  segments  of  the 
cornea,  or  by  pedunculated  flaps.  The  graft  is  rarely  used.  The 
first  is  particularly  serviceable  when  the  part  to  be  covered  is  at,  or 
near,  the  periphery,  as  cystoid  scars,  perforating  sclerocorneal  injuries, 
crescentic,  and  annular  ulcers  and  operative  incisions   (Fig.    246). 


4o6 


OPERATIONS    UPON    THE    GLOBE 


The  conjunctiva  is  incised  for  a  short  distance  vertically  to  the  cornea, 
on  ehher  side  of  the  wound,  if  the  latter  is  small  and  quite  peripheral, 
then  undermined  with  a  curved  iris  spatula,  severed  at  the  limbus, 
drawn  over  the  defect,  and  secured  with  a  suture  at  each  free  corner. 
If  a  more  extensive  area  is  involved  the  cornea  is  simply  circumcised, 
and  the  coniunctiva  dissected  loose  with  the  scissors,  to  the  requi- 


lu,.  2-^0.  Fig.  251. 

site  degree,  drawn  over,  and  fixed  with  two  sutures  (Fig.  247).  In 
this  manner,  by  completing  the  circumcision,  the  whole  cornea  may 
be  covered,  the  conjunctiva  being  held  by  the  two  sutures  (Fig.  249) 
or  by  the  purse-string  suture. 

Pedunculated   Flaps. — These   are  of   two  kinds,  those  with  a 
single  pedicle,  called  tongue fiaps,  and  those  with  double  pedicle,  or 


Fig.  252. 


Fig.   253 


bridge  flaps.  They  are  best  suited  to  lesions  whose  location  is  more 
or  less  remote  from  the  ])eri])hery,  and  the  affected  space  is  more 
circumscribed,  although  ihey  ma\'  be  adapted  to  any  region  of  the 
cornea.  When  feasible  the  tongue  llap  is  best  made  with  its  attached 
])()rtion   abo\e.      it   is  fashioned   by    first   incising   the  conjunctiva. 


KKRAIOIM.ASIY  407 

])aralk'l  with  the  liml)us,  al  a  dislancc  lluTcfrom,  and  to  an  extent, 
commensurate  with  the  desired  width  and  len,L;;th  of  the  tlaj).  I-'rom 
the  extremity  of  this,  and  corres])onding  to  the  free  end  of  the  llap, 
another  incision  to  the  liml)us.  The  jjortion  within  the  an.u;Ie  thus 
formed  is  dissected  from  the  e])iscleral  tissue,  and  the  ton,<i;ue  com- 
pleted by  severing  the  attachment  at  the  Hmbus  (Fig.  250).  It  may 
be  lixed  over  the  lesion  by  simply  spreading  it  out  well,  smoothing 
it  with  the  iris  spatula,  and  leaving  it  for  a  few  moments  before 
closing  the  eye,  or  its  tip  may  be  drawn  to  a  point  opposite  on 
the  limbus,  and  secured  with  a  suture  (Fig.  251).  The  use  of 
the  bridge  flap  is  chiefly  confined  to  central  and  ])aracentral  lesions 
of  limited  dimensions.  Like  the  tongue  flap,  it  is  best  made 
in  the  vertical  direction.  The  first  incision  is  mainly  concen- 
tric with  the  cornea,  and  half  way  around,  the  width  of  the  flap 
intervening.  It  is  loosened,  then  freed  from  the  limbus  by  an  in- 
cision that  extends  three-fourths  of  the  way  around.  This  last  in- 
cision can  be  more  neatly  made  with  a  curved  blunt  bistury,  or 
Weber's  curved  lacrimal  knife  (Plate  I,  6  and  9),  but  more  easily, 
perhaps,  with  scissors.  The  knife  cuts  closer,  and  imparts  a  more 
regular  border  to  the  flap.  Kuhnt  sometimes  makes  the  middle 
of  the  bridge,  or  just  where  it  is  to  cover  the  lesion,  somewhat  wider 
than  the  remainder.  It  is  held  by  two  sutures,  as  shown  in  Fig. 
253.  When  to  be  applied  near  the  margin  of  the  cornea  the  bridge 
flap  may  be  made  as  shown  in  Fig.  252.  Kuhnt,  has,  on  occasion, 
put  a  tongue  flap  on  the  lesion,  then  crossed  it,  at  right  angles, 
with  a  bridge  flap,  for  protection. 

The  flap  is  drawn  over  the  cornea  by  two  delicate  dressing  forceps, 
to  see  if  it  A75;  if  it  does  not,  it  will  probably  be  found  that  a  snip  or 
two  of  the  scissors,  at  its  base,  will  make  it  right.  In  dissecting  the 
conjunctiva,  especially  in  case  of  a  youthful  subject,  one  must  avoid 
including  the  episcleral  tissue.  An  ulcer  is  thoroughly  curetted, 
and  the  lips  of  a  wound,  inclusive  of  those  surrounding  a  prolapse, 
unless  quite  recent,  are  scraped  with  the  edge  of  a  scalpel  before 
putting  on  the  flap.  The  latter  is  carefully  spread  out  over  the 
defect,  with  toilet  forceps  and  spatula,  to  be  sure  that  there  is  no 
folding  under  of  the  edges,  then  pressed  upon  with  the  sharp  tip 
of  a  wet  cotton  sponge,  to  make  it  conform  to  the  topogra])hy  of  the 
part.  After  suturing,  should  the  flap  lie  too  loosely  u])on  the  cornea, 
it  is  advisable  either  to  ])ut  in  a  tension  suture,  or,  if  one  is  to  be 
replaced,  it  should  be  left  in  until  the  new  one  is  passed  through, 


4o8  OPERATIONS  UPON  THE  GLOBE 

and  partly  tied.  In  presence  of  a  rather  extensive  open  wound,  or 
an  ulcer  that  is  likely  to  perforate— is  down  to  Descemet's  membrane, 
fo  r  example — it  is  important  that  every  precaution  be  taken  to  pre- 
V  ent  pressure  upon  the  globe  during  the  operation.  The  same  holds 
good  as  regards  an  opening  that  is  to  be  made,  as  the  abscission  of  a 
cystoid  scar  or  a  staphyloma;  moreover,  in  this  event,  the  flap  to 
cover  it  should  be  ready  prepared,  and  the  suture  be  passed,  but 
left  untied,  before  the  operation  is  begun.  It  is  superfluous  to  add 
that  the  flap  must  be  surgically  clean.  It  must  also  be  somewhat 
larger  than  the  defect  to  be  treated. 

Both  eyes  are  bandaged  for  two  to  four  days,  and  the  operated 
one  for  seven  to  fourteen  days,  as  the  surgeon  sees  fit.  The  sutures 
may  be  removed  at  the  time  the  well  eye  is  left  free.  At  the  second 
dressing  the  flap  often  looks  as  if  covered  with  fibrin.  Later  it 
becomes  red  and  thicker.  Such  flaps  are  prone  to  atrophy,  but  not 
until  after  they  have  served  their  office.  Again,  they  remain  but 
little  changed,  and  necessitate  the  trimming  away,  or,  perchance,  the 
replanting  of  the  surplus  membrane  upon  its  former  site.  It  may 
be  here  mentioned  that  no  attention  is  paid  to  the  scleral  defect  that 
results  from  the  cutting  out  of  the  flap.  Peripheral  lesions  thus 
healed  are  likely  to  take  the  form  of  a  pseudopterygium,  but  it  has 
no  tendency  to  encroach  further  upon  the  cornea. 

The  indications  for  conjunctival  keratoplasty,  as  tabulated  by 
Suker  (///.  Med.  Jour.,  Nov.,  19 12)  are: 

1.  Extensive  wounds  of  the  cornea  and  sclera  with  or  without 
loss  of  substance  in  either,  or  prolapse  of  ocular  contents. 

2.  Corneal  fistulas. 

3.  Serpiginous  or  perforating  corneal  ulcers. 

4.  Corneal  or  scleral  staphyloma. 

5.  Prolapses  of  ocular  contents. 

6.  Hernia  of  the  iris. 

7.  Extensive  conical  cornea. 

8.  Untoward  conditions  in  wounds  following  cataract  extraction 
and  the  like. 

9.  As  a  protection  for  the  cornea  in  conditions  similar  to  gonor- 
rheal ophthalmia,  in  which  extensive  perforations  and  resulting 
intraocular  infections  are  liable. 

Serpiginous  ulcers  are  given  prior  treatment  by  cauterization, 
the  conjunctival  flap  being  applied  as  soon  as  the  slough  can  be  easily 
removed. 


CORNEAL   GRAFTING  409 

Corneal  Grafting. — -True  corneal  grafting,  that  is  to  say,  the 
transj)lantati()n  of  corneal  tissue  on  or  in  other  corneal  tissue,  is  of 
two  kinds — tectonic  and  optic.  The  first  has  reference  to  the  building 
on  or  up  of  new  corneal  material  to  replace  that  which  is  lost.  For 
instance,  a  large  fleshy  pterygium,  or  a  neoplasm  is  removed;  or  an 
area  is  laid  bare  by  an  operation  for  symblcpharon.  The  second, 
or  optic  grafting,  is  that  form  whereby  an  attempt  is  made  to  sub- 
stitute transparent  tissue  for  opacpie,  and  principally  concerns  cases 
wherein  exists  blindness  from  total  leucoma. 

Tectonic  Grafting. — This  variety  is  best  represented  by  the 
method  of  Diirr  {Kl.  Monats.  f.  Augenh.,  XVII,  S.  317,  1879).  In 
case  of  a  corneal  defect  of  the  kind  in  question,  and  peripherally 
located,  Diirr  transplanted  a  corneal  graft,  corresponding  in  size 


r- 


Fig.  255. 

and  shape,  but  consisting  only  of  the  anterior  layers,  and  always 
with  a  border  of  the  conjunctiva  attached,  taken  from  the  eye  of  a 
rabbit.  It  is  requisite  that  the  ground  of  the  defect  be  freshly  pre- 
pared, flat,  and  composed  of  transparent  (?)  tissue.  (Fig.  254.) 
The  conjunctiva  about  the  adjacent  limbus  is  resected,  and  the 
bleeding  stopped.  The  substitute  piece  is  taken  from  the  eye  of  a 
rabbit,  or  a  dog,  or,  when  possible,  from  a  newly  enucleated  human 
eye.  A  flap  is  made  of  the  adjoining  conjunctiva,  base  at  the 
limbus,  and  the  dissection  is  continued  into  the  corneal  substance, 
splitting  it  to  the  proper  depth  and  extent.  The  graft  may  be 
simply  smoothed  and  pressed  into  place,  but  it  is  safer,  perhaps,  to 
secure  it  by  a  suture  at  either  end  of  the  conjunctival  tag.     (Fig. 

255-) 

Optic  Grafting. — It  is  but  natural  that  surgeons  should  strive, 
as  did  Pellicr^  more  than  a  hundred  years  ago,  and  as  they  have 
striven,  at  intervals,  ever  since  to  put  windows  into  these  pitiable 
eyes.     As  yet  their  striving  has  been  mostly  in  vain  in  so  far  as  accom- 

iPellier,  Manuel  de  Lefehure  sur  les  ophtalmies,  1802. 


4IO  OPERATIONS  UPON  THE  GLOBE 

plishing  the  main  object  is  concerned.  Surely,  though,  it  will  be 
accomplished.  One  cannot  help  being  impressed  with  the  prob- 
ability of  this  when,  as  has  been  the  experience  of  many,  one  sees  a 
patient  with  purulent  ophthalmia  whose  cornea  has  just  been  com- 
pletely destroyed  by  sloughing,  yet  enabled  to  count  fingers  or  even 
to  tell  the  time  on  a  watch,  with  the  afflicted  eye  by  means  of  a  rising 
button  of  vitreous.  It  may  have  been  some  such  incident  that  turned 
Pellier's  thoughts  toward  the  possibility  of  putting  in  an  artificial 
cornea,  and  that  has  actuated  certain  others  since  his  time,  as,  for 
instance,  Nussbaum,i  ^^ho  inserted  a  double  button  of  glass  in  the 
center  of  the  cornea;  and  Dimmer, ^  who  made  similar  trial  of  a 
celluloid  disk.  These  foreign  bodies,  although  they  restored  some 
vision  for  the  moment,  either  soon  came  out  or  were  buried  beneath 
the  tissues. 

The  first  to  make  an  actual  attempt  at  optic  corneal  grafting  was 
Reisinger,^  who  but  acted,  however,  on  the  suggestion  made  to  him 
in  1813  by  his  friend  and  teacher,  Himly.^  Reisinger's  experiments 
were  upon  the  eyes  of  rabbits  and  by  total  grafting.  His  success  did 
not  encourage  him  to  continue.  Some  years  later,  Muhlbauer,^ 
proposed  the  method  of  partial  keratoplasty,  though  he  did  not 
carry  the  notion  into  execution.  Desmarres,^  imbued  with  the 
idea  of  Reisinger,  made  divers  trials  of  it  upon  animals.  He 
demonstrated  that  the  grafting  of  a  cornea  was  possible,  but  he 
found  that  the  transplanted  portion  always  lost  its  transparency, 
so  he  abandoned  the  project.  The  next  to  take  it  up  was  Power,^ 
but  chiefly  in  a  theoretic  manner.  The  most  determined  and  serious 
efforts  at  optical  keratoplasty  within  recent  years  were  those  of 
von  Hippel.^  Having,  like  Desmarres,  become  discouraged  by 
attempts  at  total  keratoplasty,  von  Hippel  finally  adopted  the  method 
proposed  by  Muhlbauer,  just  alluded  to,  viz.,  that  of  partial  kerato- 
plasty, and  devised  an  ingenious  trephine  for  cutting  both  the  cornea 
to  be  replaced  and  the  graft.  He  found  that  while  a  total  graft  would 
become  opacjue  in  2  or  3  weeks,  the  ])artial  would  remain  transparent 

»  Deutsche  Klin.  No.  34,  1853. 

2  The  Operative  Treatment  of  Total  Leucoma,  etc.,  Trans.  Heideb. 
Oph.  Scy.,  1889,  S.  147. 

s  Baerische  Ann.  .  .  .  aus  dem  Gebiete  der  Chirurg.,  etc.,  i  Heft, 
Sulzl)ach,  1824. 

••  Himly,  Krank.  und  Misshildung.  des  Aug.,  S.  60,  1843. 

'■>  Schmidt's  Jahresb.,  x.xxv,  1839. 

"  Ann.  d'oculist,  1843. 

'Trans.  London  Congress,  1873,  pp.  189-194. 

s  A.  S.  A.,  xxiii,  2,  S.  79,  1887;  xxiv,  2,  S.  335;  xxiv,  i,  S.  108,  1888. 


CORNEAL    CRAFTING  41I 

for  a  much  l()n,ti;cr  lime.  Knapn'  relates  having  seen  a  patient  pre- 
sented by  von  Hijjpel  at  the  1887  meetin,-,^  of  the  Heidelberg  ()]jlithal- 
mologic  Society,  on  whom  he  had  made  such  a  keratoplasty  more 
than  a  year  previously.  "The  i)iece  was  still  tolerably  transjjarent, 
and  the  patient  had  useful  sight."  The  ultimate  fate  of  the  best 
results  so  far  obtained  has  been  loss  of  the  restored  sight  through 
clouding  of  the  graft. 

jl^It  goes  without  saying  that  the  operation  is  not  to  be  thought  of 
in  anv  case  where  vision  can  be  restored  bv  any  other  known  means, 


i^S^^ 


''m[\^^l^^ 


Fig.   256. — Von  Hippel's  trephine. 

such  as  iridectomy.  Seeing  that  the  Descemet's  membrane  and 
even  the  deepest  portion  of  the  corneal  tissue  proper  must  be 
transparent,  the  cases  to  which  the  method  is  applicable  are  rare. 
The  graft  may  be  made  in  any  available  part  of  the  cornea.  If  the 
iris  should  be  in  the  way  of  vision  it  should  be  excised. 

The  operation  of  partial  keratoplasty  after  von  Hippel  is  brietly 
as  follows:  Local  anesthesia.  First,  one  makes  an  estimate  as  to 
the  thickness  of  the  leucoma.  This  is  done  by  lightly  pressing  upon 
it  with  a  blunt  stylet,  and  testing  the  degree  of  resistance.  Usually 
the  trepan  would  be  set  to  cut  the  depth  of  about  0.75  mm.  The 
diameter  of  the  disk  should  not  exceed  4.5  mm.  The  eye  is  steadied, 
and  the  trephine,  wdiich  works  automatically  by  a  spring,  is  made  to 
cut  to  the  indicated  depth.  The  instrument  is  removed,  and,  with 
delicate  forceps  and  knife,  the  upper  layers  of  the  outlined  j^ortion 
carefully  dissected  out,  leaving  a  flat,  transparent  bottom  to  the 
excavation.  A  young  rabbit  is  chloroformed,  the  tre])liine  is  set  for 
1.5   to   2   mm.    (for  here  the  whole    thickness  is    removed),     the 

1  Norris  and  Oliver's  System,  1898,  p.  832. 


412  OPERATIONS  UPON  THE  GLOBE 

graft  is  excised,  and  quickly  transferred  to  its  destined  place.     The 
eye  is  closed  and  bandaged.     No  sutures  are  used. 

Zirni  modified  this  operation  in  1905  by  using  a  graft  from  a 
human  cornea  instead  of  from  that  of  a  rabbit.  The  trephine  is 
used  as  in  the  von  Hippel  method.  Eserin  is  instilled  if  the  anterior 
chamber  is  present.  Zirm  gives,  as  essentials  for  the  successful 
performance  of  the  operation,  deep  anesthesia,  strict  asepsis, 
the  avoidance  of  antiseptics,  and  the  protection  of  the  graft  between 
two  pieces  of  gauze,  moistened  with  sterile  physiologic  salt  solution, 
and  keeping  it  warm  in  steam  until  it  can  be  placed  in  position.  The 
graft  is  held  in  position  by  two  conjunctival  sutures  which  pass 
over  it  in  such  a  way  as  to  form  a  St.  Andrew's  cross  at  the  center. 
In  the  case  reported  the  patient,  a  man  45  years  old,  had  5/50 
vision;  5/20  with  a  convex  lens,  and  J  13,  seven  months  after  the 
operation. 

Transplantation  of  Graft  from  Human  Cornea  previously 
preserved  in  Antiseptic  Fluid.— A.  Magitot,  of  Paris  {Jour. 
A.M. A.,  July  6,  1912)  contributes  an  interesting  article  upon  this 
subject.  Believing  that  the  only  human  transplantation  that  has 
given  encouraging  results  is  homoplasty,  i.e.,  from  man  to  man,  he 
undertook  to  obviate  some  of  the  difficulties  of  obtaining  suitable 
tissue  by  preserving  enucleated  eyes.  In  this  he  was  actuated  by  the 
work  of  Carrel,  of  the  Rockefeller  Institute,  in  connection  with  the 
blood-vessels.  In  consequence  of  much  research  and  experiment, 
Magitot  was  enabled  to  keep  viable  the  eyes  of  animals  twelve  to 
fourteen  days  after  enucleation.  The  corneas  of  living  animals 
into  which  grafts  from  the  preserved  eyes  were  inserted,  were  found 
transparent  at  the  end  of  eighteen  months.  A  slight  irregular 
astigmatism  was  the  only  indication  of  the  place  at  which  the  trans- 
plantation was  made.  Emboldened  by  the  success  of  his  experi- 
ments, he  tried  the  method  on  the  eye  of  a  fourteen-year-old  boy, 
with  opacity  of  the  cornea  from  burn  of  quicklime.  The  entire 
cornea,  with  the  exception  of  a  small  area  ujnvard  and  inward  was 
opaque.  As  the  result  of  an  optic  iridectomy  at  this  place  the  lad 
had  vision  of  2/17.  Into  this  cornea  Magitot  put  a  graft  from  a 
human  eye,  enucleated  for  absolute  glaucoma,  and  that  had  been 
preserved,  in  a  particular  manner,  for  one  week. 

The  operation  is  thus  described:  The  false  pterygium  was  first 
all  completely  dissected  off.  Then  a  rectangle,  about  4  mm.  in 
height  by  6  mm.  in  length,  was  exsccted  from  the  opaque  cornea. 


TATTOOAGE   OF   CORNEA  413 

The  cavity  was  made  as  deep  as  possible  without  perforating 
Descemet's  membrane,  and  in  such  a  fashion  that  the  edges  of  the 
wound  were  true  and  perpendicular.  Finally,  a  piece  the  same 
size  was  cut  from  the  preserved  cornea  and  applied  to  the  prepared 
spot.  The  article  thus  concludes:  "It  is  now  nearly  a  year  since 
the  operation  was  performed.  The  graft  persists  and  is  still  perfectly 
clear.  Its  transparency  is  much  greater  than  that  of  the  small  area 
beneath  which  the  iridectomy  had  been  made.  The  graft  has  the 
appearance  of  a  pane  of  glass,  or  of  a  small  window,  in  an  opaque 
wall.  The  irregular  astigmatism,  which  inevitably  follows  any  form 
of  keratoplasty,  has  greatly  diminished.  The  visual  acuity,  through 
the  graft,  has  reached  1/7,  that  is  to  say,  a  degree  that  is  more  than 
sufficient  for  the  patient  to  find  his  way  about,  and  that  permits 
him  to  read  printed  characters  of  a  fairly  large  type." 

TATTOOAGE  OF  THE  CORNEA. 

The  staining  of  the  cornea  in  cases  of  leucoma,  partial  or  total, 
is  of  ancient  origin.  Galen  practiced  cauterizing  the  surface  with 
a  red-hot  stylet  and  afterward  rubbing  into  the  raw  area  powdered 
nut-galls  mixed  with  iron  or  a  mixture  of  powered  pomegranate 
bark  and  a  salt  of  copper.  The  first  to  make  use  of  tattooage 
proper,  i.e.,  with  a  needle  and  India  ink,  which  is  the  most  approved 
substance,  was  Taylor,  the  noted  English  quack  oculist,  near  the 
middle  of  the  i8th  century.  At  first  the  ink  was  put  into  a  cannula, 
inside  of  which  the  needle  was  worked.  It  is,  however,  to  De 
Wecker^  that  we  are  mainly  indebted  for  a  distinctive  method  and 
largely  also  for  the  technic  of  the  modern  operation. 

The  object  of  tattooage  is  either  optic  or  cosmetic.  The  indica- 
tions for  optic  tattooing  would  be  found  in  such  cases  as  aniridia, 
albinism,  coloboma  of  the  iris,  and  in  diffuse  nebulosities  of  the 
cornea — the  last  in  order  to  make  the  vision  more  net.  In  these 
conditions,  of  course,  the  area  of  the  cornea  corresponding  to  the 
pupil  would  be  left  clear,  and  the  pigment  made  to  occupy  the  per- 
ipheral zone.  In  this  way  the  photophobia  would  be  lessened  and 
the  visual  acuity  increased.  The  sphere  of  cosmetic  tattooage  is 
limited  to  the  hiding,  or  rendering  less  conspicuous,  of  opacities  of  the 
cornea.  Both  kinds  can  be  made  to  serve  useful  ends,  for,  even  as 
to  the  second,  it  is  an  indisputable  fact  that  little  blemishes  of  face 

'  'Union  med.,  mars,  1870,  and  Chirurg.  oculaire,  p.  181. 


41-4  OPERATIONS    UPON    THE    GLOBE 

and  figure  constilulc  a  decided  handica])  in  the  great  bread-winning 
race  as  regards  both  male  and  female. 

The  method  of  procedure  is  the  same  in  both  kinds  of  tattooage. 
The  instruments  are  blepharostat,  hxation  forceps  with  broad  jaws 
and  no  teeth,  one  instrument  containing  four  needles  in  a  compact 
bundle  for  work  in  a  circumscribed  area,  one  with  four  needles  in  a 
row  for  broader  areas,  and  a  tiny  curved  spatula  for  applying  the 
ink  to  the  surface  to  be  tattooed  (Plate  II,  Nos.  24  and  25).  The 
needles  must  be  quite  sharp.  The  best  grade  of  India  or  Chinese 
ink,  in  cake,  is  approj)riatc  for  all  cases,  excepting  where  hazels 
and  browns  are  to  be  simulated;  for  these  admixtures  of  sepia  of 
vermilion  and  ultramarine  are  required.  A  piece  is  cut  or  broken 
from  the  cake  and  sterilized  by  baking  for  half  an  hour  at  a  tem- 
perature of  150°.  It  is  then  taken  in  sterile  forceps  or  crayon- 
holder,  dipped  in  water  or,  what  is  probably  better,  a  solution  of 
gum-arabic,  and  rubbed  in  the  bottom  of  a  paint  saucer,  dipping 
occasionally  for  a  fresh  drop  of  the  liquid,  till  a  few  drops  of  a  thin 
black  paste  are  obtained.  If  done  rightly,  this  process  is  tedious. 
The  finer  the  subdivision  of  the  particles,  the  better.  Of  course, 
the  ink  must  be  used  as  soon  as  prepared.  The  colored  pigments 
may  be  procured  in  fine  powder,  then  washed,  first  in  water,  then  in 
alcohol,  then  in  ether;  evaporated  in  a  sand-bath  and,  lastly  steril- 
ized as  above,  and  mixed  with  aseptic  gum-arabic  solution. 

Technic  of  the  Operation.  Local  Anesthesia.— After  washing 
the  conjunctixal  sac  with  boric  acid  solution,  the  cornea  is  dried  with 
the  tip  of  a  small  cotton  sponge  from  which  the  moisture  has  been 
well  wrung.  Some  operators  prefer  to  mark  the  pu])illary  area  with 
the  edge  of  a  sharp  cylinder  and  to  remove  the  epithelium  within 
the  circle  before  applying  the  pigment,  but  this  is  unnecessary. 
A  drop  of  the  ink  the  size  of  a  pinhead  is  taken  up  with  the  s])atula 
and  de])Osiled  exactly  on  the  spot  to  be  tattooed.  If  the  area  is  small, 
with  the  bunched  needles  one  pricks  the  spot  through  the  mass  of 
ink.  'Hie  needles  are  jabbed  in  both  perpendicularly  and  obliquely, 
and  until  the  color  is  sufficiently  dense.  The  aim  is  to  get  the  ink 
deep  in  the  corneal  substance  without  perforating.  If  rather  free 
bleeding  occurs,  it  may  be  stopped  for  a  time  by  adrenalin  solution — 
else  the  operation  sliould  l)e  ])ost])oned.  Indeed,  a  single  sitting 
never  suffices  for  an  effective  and  lasting  result;  from  three  to  five 
or  even  more  being  re(|uire<l,  with  a  week's  interval  between.  It 
has  been  eslinialed   tiiat   from    100  to   120  ])ricks  at  a  sitting  are 


TATTOOAC.K    OF    CORXKA  415 

necessary  to  o]:)lain  a  t^ood  black  |)U])il,  and  as  many  as  2,000  where 
the  leucoma  is  large  and  the  j)erii)heral  ])()rli()n  is  made  to  simulate 
the  iris.  One  should  practise  tattooage  on  fresh  pigs'  eyes,  then 
examine  sections  of  the  cornea  microscopically,  in  order  to  get  an 
idea  as  to  the  proper  force  one  should  impart  to  the  strokes  of  the 
needle  instrument.  Considerable  judgment  and  skill  are  needed 
to  do  the  thing  right.  If  one  is  uncertain  of  his  hand  in  the  matter, 
he  should  confine  the  maneuver  to  the  slanting  strokes.  Every 
little  while  the  pricking  must  be  stopped  while  the  cornea  is  wiped 
clean  and  warm  boric  or  salt  solution  is  gently  i)oured  over  it,  and 
note  made  of  the  effects — distribution  of  the  pigment,  etc.  Through- 
out, an  assistant  keeps  the  lower  conjunctival  fornix  free  from 
fluid,  but  sponges  the  cornea  only  at  the  surgeon's  bidding.  Most 
surgeons  recommend  using  the  needles  on  the  bare  cornea,  that  is, 
before  applying  the  ink,  then  rubbing  the  latter  in  with  ihc  Jiiif;cr. 
"While  I  have  no  exact  data  to  prove  the  assertion,  it  but  stands  to 
reason  that  a  greater  quantity  of  pigment  can  be  driven  into  the 
cornea  by  piercing  it  through  the  mass  of  finely  divided  ink  than 
could  be  rubbed  in.  There  can  be  no  harm  in  rubbing,  however, 
but  let  it  be  by  the  back  of  a  tiny  spoon  or  the  like — not  in  this 
primitive  and  unsurgical  manner  with  the  finger.  The  ink  and  the 
slightly  fibrinous  exudation  from  the  cornea  form  a  sort  of  pseudo- 
membrane  that  rather  resists  one's  efforts  to  wipe  it  off.  I  fancy 
that  this,  by  the  entanglement  of  the  pigment,  tends  to  prevent  the 
needles  from  driving  it  in;  hence,  another  reason  for  frequent 
pauses  and  cleansing  of  the  cornea.  The  eye  is  bandaged  and  the 
patient  cautioned  to  remain  very  quiet  for  forty-eight  hours.  The 
reaction  is  usually  slight.  Armaignac,  of  Bordeaux, ^  employs 
dome-shaped  metal  shields  with  various-sized  circular  openings  at 
the  top  as  guides  to  tattooage — those  with  the  smaller  perforations 
are  for  doing  the  pupillary  area,  those  with  the  larger  for  the  iris 
zone.  The  shield  is  held  firmly  on  the  globe  while,  with  a  four- 
needle  instrument,  the  exposed  space  is  rapidly  pricked. 

The  operation  of  tattooage  has  been  decried  by  some  because  of  a 
supposed  tendency  to  jjroduce  sympathetic  ophthalmia.  I  cannot 
see  any  reason  for  its  being  a  dangerous  procedure.  It  must  be 
remembered  that  eyes  that  are  afflicted  with  leucoma  of  the  cornea 
are  prone  to  inflammations  and  degenerative  changes  that  some- 
times lead  to  symi)athetic  trouble.     It  were  well,  then,  for  his  own 

1  Reccuil  cl'opht.,  Aug.,  190J;. 


41 6  OPERATIONS  UPON  THE  GLOBE 

peace  of  mind,  if  nothing  more,  that  the  surgeon  exercise  discretion 
in  selecting  cases  for  tattooage.  The  eye  should  be  absolutely 
quiet,  the  globe  in  nowise  atrophied,  free  from  partial  staphyloma, 
any  extensive  adhesions  between  iris  and  cornea,  and  from  septic 
disease  of  the  conjunctiva  and  lacrimal  canal. 

Anatomic  investigation  of  tattooed  cornea  by  Alt,^  Browicz,^ 
Hirschberg,^  and  others  have  shown  that  the  particles  of  carbon 
which  at  first  occupy  the  needle  punctures  almost  immediately 
begin  a  slow  migration,  which  probably  never  entirely  ceases. 
After  some  months  or  a  year,  they  are  found  sparsely  among  the 
deepest  layers  of  epithelial  cells,  but  their  chief  abiding  place  is  in 
the  anterior  half  of  the  stroma,  being  thickest  in  the  layer  immedi- 
ately beneath  Bowman's  membrane.  They  accumulate  in  the 
lymph  spaces  in  the  form  of  flakes  and  balls,  while  the  smaller  ones 
are  dispersed  among  the  neighboring  structures,  some  enclosed  by 
the  corneal  corpuscles  and  by  the  fixed  and  lymphoid  cells.  They 
even  find  their  way  into  the  walls  and  endothelium  of  the  blood 
vessels.  This  dispersion,  fortunately,  is  less  rapid  in  proportion 
as  the  leucoma  is  dense,  i.e.,  as  the  cornea  is  degenerated. 

Only  pigments  that  are  insoluble  in  water  are  suitable  for  tat- 
tooage, the  best  being  ultramarine,  cinnabar,  sepia,  ochre,  and 
lampblack.  Woinow,^  Vocher,^  and  Hock^  have  written  on  multi- 
color tattooage. 

The  Influence  of  Tattooing  of  the  Cornea  on  the  Visual 
Acuity. — Dr.  Nagoya,"  Mageda,  Japan,  reports  30  cases  out  of 
58  in  which  he  had  splendid  optical  results  with  tattooing  of 
semitransparent  maculae  of  the  cornea  with  India  ink.  On  three 
plates  he  demonstrates  by  his  photographic  method  very  instruc- 
tively the  impairment  of  vision  by  macular  of  the  cornea  and  the 
improvement  by  tattooing  them.  With  the  Zeiss  lens  "unar"  and 
iris  diaphragm  of  15  mm.  diameter  he  photographed  a  diploma. 
If  one-half  or  the  center  of  the  anterior  surface  of  the  photographic 
lens  was  painted  with  paste,  the  photograph  was  indistinct;  if  the 
painted  surface  was  then  blackened  with  India  ink  the  distinctness 
of  the  pictures  remained  iinintUienced. 

lAm.  Jour,  of  Ophy.,  i,  p.  8,  1884. 

2A.  S.  O.,  xxiii,  23,  S.  212. 

3 A.  S.  O.,  xxviii.i,  S.  269,  ff,  1882. 

^Trans.  Russian  Scy.  of  Physicians,  Moscow,  1872,  No.  13. 

^  Bull,  ct  m6Tn  de  la  soc.  fran?.  d'opht.,  5  me  ann6e,  1887,  p.  24S 

"A.  S.  A.  u.  O.,  1876,  vol.  i,  S.  go-roi. 

^  Beitrage  zur  Augenheilkunde,  1905,  Heft  64,  p.  232. 


SC'LEKOTOMY  417 

OPERATIONS  UPON  TUK  SC'r.KRA. 

As  Czermak  quite  rightly  observes,  with  the  excej^tion  of  the 
suturing  of  traumatisms  and  a  few  minor  operations,  such  as  curettage, 
etc.,  all  the  operations  u])()n  tlie  sclera  arc  undertaken  not  because 
of  any  disease  or  defect  of  this  tunic  itself,  but  for  the  relief  of  those 
incident  to  one  of  the  other  coats  or  of  the  entire  globe.  They  are, 
sclerotomy,  anterior  and  ])osterior;  excision  (trej)hination) ; 
galvano-puncture,  and  suturing. 

SCLEROTOMY. 

Incision  of  the  sclera,  sclerotomia,  is  of  two  kinds — anterior 
and  posterior — so  named  from  the  situation  of  the  o[)eration  with 
reference  to  the  iris  and  ciliary  body. 

Anterior  Sclerotomy. — The  idea  that  the  efficacy  of  the  oj)era- 
tion  of  iridectomy  for  glaucoma  was  due,  not  so  much  to  the  excision 
of  iris  as  to  the  scleral  incision,  seems  to  have  occurred  first  to  De 
Wecker.^  x'Vbout  the  same  time,  Stellwag  v.  Carion,  who  had  formed 
a  similar  opinion,  -  mentions  that  in  a  case  of  double  glaucoma  he  made 
iridectomy  u})on  one  eye  and  merely  the  incision  upon  the  other,  and 
that  the  result  was  equally  good  in  both.  The  first,  however,  to  system- 
atically practise  anterior  sclerotomy  for  glaucoma  was  Quaglino,^  who 
reported  five  cases  of  glaucoma  in  wdiich  he  had  made  the  operation, 
giving  favorable  results.  Quaglino  made  the  incision  with  a  large, 
triangular  keratome,  much  in  the  usual  way  for  iridectomy,  the 
only  differences  being  that  he  began  the  scleral  incision  2  mm. 
behind  the  sclero-corneal  junction,  pushing  the  blade  very  slantingly 
through  into  the  anterior  chamber.  Then,  before  withdrawing, 
he  tilted  the  handle  back,  and,  slightly  Jirying  open  the  cut,  allowed 
the  aqueous  to  run  out  very  slowly,  to  avoid  prolapse  of  the  iris. 
The  same  year  that  Quaglino  made  his  report,  De  Wecker,'*  gave 
an  account  of  seven  cases  of  glaucoma  in  which  he  made  anterior 
sclerotomy  by  a  new  method,  which  he  called  ^'incision  double 
QTc'cc  pout  sdero-conjiDirlival.'"  This,  which  has  been  followed, 
perhaps,  oftener  than  any  other  mode  of  anterior  sclerotomy,  is  as 
follows:     The  pupil  is,   if  possible,  contracted  by  eserin,  then  the 

1  Traite  des  maladies  des  yeux.  1867. 

2  Der  Intraoculjire  Druck,  Wein,  1868. 

3  Annali  di  Ottala.,  1871,  p.  200. 
^  Ann.  d'oculist.,  1871. 


4l8  OPERATIONS    UPON    THE    GLOBE 

eye  is  lightly  cocainized.  With  a  narrow  Graefe  knife,  puncture 
and  counterpuncture  are  made  above  i  mm.  back  of  the  limbus, 
as  if  for  linear  extraction  with  flap  2  mm.  high.  The  knife  is 
carried  upward  with  slow  sawing  movement  until  the  edge  engages 
well  in  the  angle  of  the  iris,  when,  instead  of  cutting  out,  it  is  twisted 
a  little  on  its  axis  to  allow  all  the  aqueous  to  escape,  then  withdrawn, 
leaving  undivided  a  bridge  of  sclera  and  conjunctiva,  about  3  or 
4  mm.  wide— or  about  one-third  of  the  distance  between  the  points 
of  the  i)uncture  and  counterpuncture.  The  points  claimed  for  the 
procedure  over  the  completed  incision  were  freedom  from  iris 
complications,  staphylomatous  scar,  loss  of  vitreous,  and  relapses. 

Wiegmani  designed  a  double  keratome  for  making  the  De  Wecker 
incision. 

A  Few  of  the  Many  Other  Modifications.— Panas^  gave  a 
method  of  anterior  sclerotomy  which  he  called  ouletomie,  specially 
destined,  as  its  name  implies,  for  incising  the  cicatrix  in  cases  of 
relapsing  glaucoma  after  iridectomy,  where  adhesions  and  inclusions 
of  the  iris  had  occurred.  This  consisted  in  making  the  usual  punc- 
tures with  very  narrow  Graefe  knife  near  the  ends  of  the  remaining 
cicatrix,  and  so  completing  the  section  as  to  include  the  entangled 
iris  and  scleral  scar,  but  left  intact  a  narrow  bridge  of  conjunctiva. 
At  times  he  also  divided  the  latter.  De  Wecker^  made  a  similar 
operation  which  was  named  "  cicatrisotomy." 

Tailor,-*  under  the  name  "internal  sclerotomy,"  gave  a  measure, 
and  for  the  execution  thereof  Vicentiis^  designated  an  instrument 
consisting  of  a  needle-like  shaft,  bearing  at  its  extremity  a  tiny, 
sharp,  sickle-shaped,  or  slightly  curved  blade,  with  the  cutting  edge 
on  the  convex  side;  blade  and  shaft  being  so  designed  that  the  latter 
effectually  stops  the  incision  made  by  the  former  and  prevents  the 
premature  escape  of  aqueous.  The  blade  is  passed  into  the  anterior 
chamber  on  a  level  with  the  horizontal  diameter  of  the  cornea,  and 
15  mm.  in  front  of  the  limbus,  carried  across  to  the  other  side,  where 
the  convex  edge  is  pushed  into  the  angle  of  the  iris;  the  handle  is 
given  a  sort  of  rotary  motion,  whereby  the  scleral  border  of  the  iris 
is  severed  and  the  sclera  itself  cut  to  the  depth  of  about  i  mm. 
The  Scleriritomy  of  Nicati/' — The  very  narrow  Graefe  knife 

1  Kl.  Mbl.  F.  A.,  1897,  p.  277. 

2  Soc.  franc,  d'opht.,  1883. 

■■' Ann.  d'oculistc,  xciii,  p.  10,  1885. 

'  Annali  di  Ottal.,  .\x,  i8gi,  p.  117. 

^  Soc.  It.  d'oijht.,  14  session,  Veniso,  1895. 

«  Bull,  et  nu'ni.  dc  la  soc.  frani^.  d'oi)ht.,  1892,  p.  278. 


AN'I'KKIOR    SCLKROTOMV 


419 


is  passed  through  the  anterior  chamber  at  the  bottom,  with  its  edge 
in  the  angle  of  the  iris.  When  the  point  is  fairly  through  the 
conjunctiva  on  the  opposite  side,  a  quick,  quarter  turn  is  given  the 
blade,  bringing  its  plane  at  a  right  angle  to  that  of  the  iris,  edge 
backward.  The  ac(ueous  here  escapes,  causing  the  knife  to  snip 
into  the  iris.  Now,  with  a  rapid  movement,  the  blade  is  withdrawn, 
so  manipulating  the  handle  as  to  incise  the  root  of  the  iris  all  the 
way.  Care  is  taken  to  pry  open  the  wound  with  the  spatula  to 
allow  the  blood  to  escape.  The  indications  given  are  secondary 
glaucoma  from  incarceration  of  iris,  cystoid  scar,  occlusion  of  the 
pupil,  and  primary  senile  glaucoma. 

Knies^  gave  what  he  termed  "irido-sclerotomy,"  made,  under 
myosis,  by  upward  section  with  the  Graefe  knife,  and  in  such  a  manner 
as  to  divide  the  root  of  the  iris  from  the  sclera  in  cutting  out — as  it 
were — a  sort  of  iridodialysis.  Sometimes  a  bridge  of  conjunctiva 
is  left  intact.  The  indications  cited  are  the  same  as  those  for 
iridectomy  and  anterior  sclerotomy  in  general. 

De  Wecker's-  sclerotomie  combinee  has  also  as  principal 
object  the  making  of  artificial  iridodialysis.  Myosis  is  produced, 
where  possible,  and  i  drop  of  cocain  solution  instilled.  The 
incision  is  made  as  for  ordinary  iridectomy,  beginning  i  mm. 
behind  the  limbus,  but  with  that  surgeon's  own  stop-knife.  The 
aqueous  is  evacuated  slowly.  A  special  forceps  is  introduced. 
When  the  closed  jaws  are  seen  2  mm.  from  the  base  of  the  cornea, 
they  are  opened,  the  iris  is  caught  near  the  periphery,  and  the  forceps 
pushed  downward,  hugging  the  posterior  surface  of  the  cornea, 
till  the  iris  is  torn  for  a  distance  of  6  to  8  mm.  from  its  fastening. 
The  forceps  is  now  withdrawn,  but  in  doing  so  one  must  not  forget 
that  the  jaws  must  be  first  opened. 

Galezowski,^  too,  has  furnished  a  measure — crucial  sclerotomy 
— and  a  special  keratome  with  which  to  make  it.  The  blade  of  the 
instrument  is  lanceolate,  measuring  3  mm.  at  its  greatest  width  by 
about  2  centimeters  in  length,  and  is  slightly  curved  on  the  flat.  It  is 
put  through  the  anterior  chamber  tw^ice,  convexity  toward  the  iris,  so 
as  to  incise  the  sclera  at  the  four  cardinal  points.  Thus  is  obtained 
the  maximum  of  severance  (12  to  14  mm.),  with  the  minimum  of 
risk.     The  second  passage  of  the  knife  can  hardly  be  an  easy  one. 

The  indications  for  anterior  sclerotomy  are: 

1  Vers,  der  Ophth.  Ges.  zu  Heidelberg,  1893,  S.  118. 

2  Annal  d'oculist.,  t.  cxii,  1894,  p.  261. 
'  Congr.  de  chir.,  Paris,  1898,  p.  175. 


420  OPERATIONS  UPON  THE  GLOBE 

(a)  Glaucoma  simplex,  especially  as  a  tentative  measure. 

(b)  As  a  preparatory  step  to  iridectomy  when  T  is  hi£i;h  and 
anterior  chamber  obliterated. 

(c)  Congenital  glaucoma,  or  hydrophthalmus. 

((/)  For  relief  of  pain  in  hemorrhagic  and  absolute  glaucoma. 

(e)  For  relapsing  glaucoma  after  iridectomy. 

As  a  matter  of  fact,  whatever  of  benefit  resulted  was  probably 
due  to  the  paracentesis  rather  than  to  the  character  of  the  incision, 
and  the  measure  in  all  its  forms  has  practically  been  abandoned. 
Yet  there  was  a  time,  a  few  years  after  De  Wecker,  with  character- 
istic zeal,  took  the  matter  up,  that  it  had  a  veritable  boom,  and 
bade  fair  to  supersede  the  operation  of  iridectomy  as  a  cure  for 
glaucoma. 

POSTERIOR  SCLEROTOMY. 

SCLERAL  FUNCTION.       PARACENTESIS   SCLER.E. 

Incisions  of  the  posterior  segment  of  the  sclera  were  made  early 
in  the  century,  James  Ware,  of  London,  having  practised  it  for 
detachment  of  the  retina  in  1805.  Later,  Sichel,  v.  Arlt,  and  De 
Wecker  resorted  to  it  in  the  same  connection.  Function  of  the  sclera 
had  been  done  also  for  general  staphyloma  of  the  globe.  The  first, 
however,  to  employ  the  operation  for  hydrophthalmus  and  glaucoma 
was  William  MacKenzie,  of  Glasgow,  about  the  year  1830.  He 
made  the  operation  with  a  lance  knife,  choosing  as  the  site  about 
the  same  part  of  the  sclera  in  which  the  old  scleronyxis  was  made 
for  couching.  After  piercing  the  vitreous,  the  knife  was  slightly 
turned  to  pry  open  the  wound.  It  fell  into  disuse  for  the  diseases  in 
question,  to  be  revived  by  de  Luca,i  who,  it  seems,  was  ignorant  of 
MacKenzie's  use  of  it.  De  Luca  made  the  incision,  not  only  in 
blind  eyes,  to  relieve  pain,  but  in  those  that  still  possessed  vision. 

The  simplest  method  for  posterior  sclerotomy  and  the  one  com- 
monly chosen  is  as  follows:  The  eye  is  cocainized.  The  patient 
is  made  to  rotate  the  eye  far  up  and  in;  the  globe  is  steadied  by 
grasping  with  fixation  forceps  the  conjunctiva  near  the  infero- 
temporal  quadrant  of  the  cornea.  A  point  is  sought  between  the 
tendons  of  the  external  and  inferior  rectus  muscles  and  at  least  15 
millimeters  back  of  the  corneal  limbus,  that  is  free  from  the  larger 
blood-vessels.     Here  a  Gracfe  knife  is  inserted  to  the  depth  of  5  or 

1  Annali  di  Ottal.,  ii,  1872,  p.  155. 


POSTERIOR  SCLEROTOMY  421 

6  mm.,  perpcndicLiUir  to  the  center  of  the  globe,  with  its  edge  directed 
forward,  and  by  a  gentle  sawing  movement,  a  meridional  incision, 
some  5  or  6  mm.  in  length  is  made.  Before  withdrawing  the  knife 
it  is  slightly  turned  on  its  axis  to  pry  open  the  cut.  A  bleb  of  con- 
junctiva arising  tells  of  the  escape  of  the  contents  of  the  globe,  and 
gives  an  idea  as  to  the  quantity.  The  knife  is  removed  and  the  eye 
washed  and  bandaged. 

While  the  technic  of  the  operation  is  simple,  yet  it  is  by  no  means 
a  measure  to  be  slighted.  Among  the  things  to  be  avoided  are 
wounding  of  the  larger  blood-vessels  of  the  conjunctiva.  Tenon's 
capsule  and  sclera  (vasa  vorticosa),  carrying  the  incision  too  far 
forward,  i.e.,  into  the  ciliary  body,  pressure  upon  the  globe  after  the 
incision  is  made,  either  by  the  surgeon  with  fixation  forceps  or  by  the 
patient  with  the  orbicularis,  and  needless  wounding  of  the  vitreous. 
To  avoid  squeezing,  the  lids  would  better  be  held  apart  by  an  as- 
sistant with  retractors. 

Modifications. — In  order  the  more  surely  to  obtain  a  fdtration 
cicatrix  and  to  protect  the  scleral  wound,  Baudry^  recommends 
drawing  the  conjunctiva  to  one  side  before  making  the  incision,  so 
that  the  two  wounds  will  not  coincide.  To  prevent  too  rapid 
healing  of  the  incision,  Parinaud,^  after  making  the  meridional 
incision,  before  withdrawing,  gives  to  the  blade  a  quarter  turn  and 
makes  a  V-shaped  scleral  wound.  For  the  same  reason,  Terson,^ 
on  completing  the  usual  incision,  withdraws  the  knife  and  makes  an 
equatorial  incision,  the  whole  wound  thus  taking  the  form  of  a  T. 

Others,  again,  either  as  a  curative  or  a  tentative  measure  in 
glaucoma,  have  practised  the  sclerotomy  without  the  retinotomy 
and  the  choroidotomy.  Masselon,^  made  a  long,  meridional  incision 
of  the  sclera  alone,  by  using  an  extremely  narrow  Graefe  knife, 
passing  it  through  by  puncture  and  counterpuncture  from  before 
backward.  Later,  he  added  a  very  small  equatorial  incision. 
Simi,^  and  Galezowski,^  made  similar  incisions,  the  latter  using  for 
the  purpose  a  knife  of  his  own  invention. 

The  writer,  in  cases  of  glaucoma  wdiere  the  eye  still  has  useful 
sight,  and  there  is  great  tension,  absence  of  anterior  chamber,  and, 
especially,  if  there  is  likelihood  of  expulsive  choroidal  hemorrhage 

1  Technique  Operatoire,  1902,  p.  639. 

2  Arch,  d'opht.,  v,  1885,  p.  180. 
5  Midi,  medical,  du  8  oct.,  1892. 

*  Ann.  d'ocuL,  t.  xcv,  p.  231,  1886. 
5  Boll  d'ocul.,  ix,  3,  1887. 

*  Seventh  Internat.  Oph.  Congress,  Heidellierg,  t888. 


422  OPERATIONS  UPON  THE  GLOBE 

from  an  iridectomy,  would  advise  making  the  posterior  sclerotomy 
between  the  intcnial  and  inferior  rectus  muscles.  In  this  way,  any 
resulting  accident  at  the  site  of  the  puncture,  within  the  globe,  such 
as  hemorrhage,  detachment  of  the  retina,  edema,  etc.,  are  further 
removed  from  the  macula.  To  favor  greater  precision,  the  over- 
lying membranes  are  first  incised.  They  are  then  retracted  by  two 
Stevens  squint  hooks.  After  the  sclerotomy,  the  membranes  are 
carefully  arranged,  but  no  suturing  is  done. 

The  alleged  indications  for  posterior  sclerotomy  are: 

1.  [a)  In  chronic  (simple)  glaucoma,  with  approaching  blindness, 
and  other  operative  measures  and  forms  of  treatment  have 
availed  nothing. 

{h)  In  absolute  glaucoma,  for  relief  of  pain,  or  for  quieting  the 
eye  in  cases  where  enucleation  is  not  practicable. 

(c)  In  irritative  primary  or  secondary  glaucoma,  with  absence 
of  anterior  chamber,  excessive  tension,  etc.,  either  as  a  preliminary 
to  iridectomy  or  as  a  last  or  only  surgical  resort  for  relief. 

2.  In  detachment  of  the  retina. 

3.  In  hemophthalmia,  especially  where  the  blood  is  in  con- 
siderable quantity  and  is  causing  high  tension,  or  organization  of 
the  clot  is  feared. 

4.  In  abscess  of  the  vitreous,  as  in  panophthalmitis,  when  one 
wishes  to  avoid  enucleation  or  exenteration. 

5.  In  cases  of  foreign  bodies  or  cysticercus  in  the  vitreous  chamber, 
to  gi\e  access  for  their  removal. 

6.  In  total  ectasia  of  the  sclera,  in  lieu  of  a  more  radical  measure. 
Cyclodialysis. — Heine,  first  assistant  in  the  clinic  of  Professor 

I'luhoU,  of  Jkeslau,!  actuated  by  the  idea  conveyed  in  the  observa- 
tions of  Fuchs  and  Axenfeld,  relative  to  detachment  of  the  choroid, 
following  incisions  affecting  the  sinus  of  the  anterior  chamber,  has 
proposed  a  new  operation  for  glaucoma.  Fuchs  had  remarked 
upon  the  relative  frequency  of  such  detachment  after  all  operations 
wherein  the  outer  limits  of  the  chamber  were  incised;  and  Axenfeld 
declared  that  it  occurred  in  as  many  as  10%  when  the  interference 
had  been  for  glaucoma.  In  consequence,  these  clinicians  were 
led  to  believe  it  possible  that  both  the  detachment  and  the  beneficial 
results  of  the  glaucoma  operation  were  caused  by  the  loosening  of 
the  choroid  from  the  sclera  incident  to  the  making  of  the  incision. 
Thereupon  I  k-inc  imagined  the  surgical  measure  for  glaucoma  which 
'  Deutsclu-  iiu'd.   \V(h1i.,  Nu.  21,  p.  S.'4. 


CYCLODIALYSIS 


423 


he  calls  cyclodialysis,  and  which  consists  in  an  attempt  to  establish  a 
lasting  communication  between  the  anterior  chamber  and  the  supra- 
choroidal  space.  Heine  proceeded  to  try  the  measure  upon  20 
glaucomatous  eyes  that  were  totally  blind  or  nearly  so.  These 
experiments  demonstrated  to  his  satisfaction  that  the  effect  of 
the  procedure  was  to  permanently  reduce  the  tension,  even  in  cases 
of  absolute  glaucoma.  Briefly,  the  operation  may  be  thus  described : 
A  triangular  flap  of  conjunctiva  8  or  9  mm.  high  is  fashioned, 
downward  and  outward,  with  its  base  left  attached  at  the  limbus. 
A  suture  is  put  into  the  apex  and  the  flap  turned  down  over  the 
cornea.     The  episcleral  tissue  in  the  exposed  triangle  is  scraped 


I'IG.    2:;7.-r\TU 


Jntision  with  lane  i'  kcratonif. 


away.  With  a  small  bent  lance  or  a  Gracfe  cataract  knife  a  2  or  3 
mm.  long  incision  is  made  in  the  sclera,  4  or  5  mm.  from,  and 
parallel  with,  the  limbus,  directing  the  point  of  the  knife,  if  it  be 
the  lance,  toward  the  chamber  angle,  but  not  entering  it.  Meller^ 
advises  making  the  cut  not  with  the  point  of  the  lance,  but  with 
one  of  its  lateral  edges,  so  that  more  nearly  the  same  depth  can  be 
1  Ophthalmic  Surgery,  190S,  p.  201. 


424 


OPERATIONS    UPON    THE    GLOBE 


maintained  along  the  whole  extent  of  the  wound.  A  narrow 
spatula,  similar  to  that  used  in  replacing  the  iris,  only  with  five 
transverse  lines  on  its  concave  surface  marking  the  5  terminal 
mm.  of  the  blade,  is  introduced  at  the  wound.  When  the  fourth 
mark  is  about  entering,  the  resistance  of  the  ligamentum  pectinatum 
is  felt.  After  this  is  slowly  pierced,  the  spatula  is  visible  in  the 
anterior  chamber.  By  lateral  excursions  this  cyclodialysis  is 
enlarged  2  to  3  mm.  No  aqueous  escapes  if  the  instrument  is 
slowly  extracted.  If,  however,  an  evacuation  of  some  aqueous  is 
desired,  the  spatula  may  be  pressed  toward  the  globe  or  a  little 


Fig.  258. — Cyclodialysis.     The  dialysis. 


twisted  to  pry  o])cn  the  wound.  Finally,  the  suture  is  tied.  If  no 
aqueous  has  been  allowed  to  escape,  there  is  no  immediate  effect 
upon  the  tension,  but  after  two  or  three  days  it  will  be  found  to  have 
decreased.  After  escape  of  aqueous  tension  is  at  once  diminished. 
In  certain  cases  it  would  certainly  seem  advisable  to  let  out  a  part 
of  the  a(|ue()us  and  reduce  the  tension  at  once,  and  also  follow  the 
operation  by  the  use  of  miotics,  so  as  to  draw  the  root  of  the  iris 
away  from  the  angle  of  the  anterior  chamber  and  thus  augment  the 
effect  of  the  operation. 


CYCLODIALYSIS 


425 


Most  surgeons  arc  accustomed  to  make  the  conjunctival  fliiy) 
more  ample  than  comports  with  the  foregoing  description,  and  tiic 
scleral  incision  somewhat  longer.  Since  the  latter  passes  slantingly 
through  the  sclera,  the  outer  wound  opening  is,  of  necessity,  larger 
than  the  inner;  so  that  in  order  to  ha\c  the  inner  one  ample — say 
2  to  3  mm.  in  extent — the  external  one  should  be  at  least  3  or  4  mm. 
A  convex  scalpel  serves  me  best  for  this  incision,  as  does  Elschnig's 
instrument  for  the  dialysis  (Fig.  259).  Its  curvature  exactly  fits 
that  of  the  globe,  and  the  length  of  its  blade  admits  of  just  the  right 
degree  of  entrance. 


3>= 


Fig.  259. — Elschnig's  spatula,  or  diaiysis. 

Indications  for  Cyclodialysis : 

1.  In  secondary  glaucoma,  especially  with  anterior  synechia 
due  to  wounds,  ulcers  or  cataract  extraction. 

2.  In  glaucoma  where  the  other  eye  has  been  lost  by  severe 
hemorrhage  following  iridectomy. 

3.  In  the  aged  or  infirm  where  it  is  considered  dangerous  to  keep 
the  patient  in  bed  as  in  iridectomy. 

4.  As  a  preliminary  operation  where  iridectomy  is  dangerous 
on  account  of  very  high  tension,  no  anterior  chamber,  atrophic 
iris  and  wide  pupil,  as  it  lowers  the  tension,  and  there  is  no  danger 
of  striking  the  lens  during  its  performance. 

5.  When  the  lens  has  been  dislocated  and  fallen  into  the  vitreous 
chamber.  Iridectomy,  for  the  secondary  glaucoma  of  such  cases, 
is  not  feasible  because  of  the  certainty  of  losing  vitreous. 

Contraindications. 

Seclusio  pupillai,  iris  bombe,  sarcoma  of  the  choroid,  or  active 
iritis. 

Accidents  and  Complications.     Immediate. 

1.  Failure  to  cut  all  of  the  scleral  fibres.  The  spatula  will  then 
go  only  about  i  mm.  forward. 

2.  Hemorrhage  from  cyclon  or  scleral  vessels  or  ciliary  vein. 

3.  Running  of  spatula  into  a  good  scleral  spur. 

4.  Detachment  of  Descemet's  membrane  from  the  corneal  stroma, 
indicated  by  corneal  cloudiness. 


426  OPERATIONS  UPON  THE  GLOBE 

5.  Iridodialysis — which  is  infrequent. 

6.  Hemorrhage  from  Schlem's  canal,  as  its  inner  wall  is  formed 
by  the  ligamentum  pectinalum  and  the  fibres  of  the  ligament  are 
broken  and  split  up. 

Consecutive  Accidents. — \\'hile  the  operation  is  of  too  recent 
origin  to  permit  one  to  judge  as  to  its  remote  effects,  tumors,  which 
are  apparently  implantation  cysts,  have  been  observed  to  occur  at 
the  seat  of  the  operation  as  early  as  a  few  wrecks  after  its  performance. 
Two  such  cases  have  been  seen  by  the  writer. 

Results  of  Cyclodialysis. — Lowering  of  tension — immediate 
if  aqueous  is  permitted  to  escape,  gradual  if  the  aqueous  is  not 
allowed  to  escape,  so  that  the  maximum  effect  is  not  produced 
until  from  one  to  three  days  after  the  operation.  These  results 
may  be  permanent  or  of  only  a  few  days'  duration.  In  some 
cases,  especially  in  absolute  glaucoma,  there  is  no  improvement 
at  any  time.  It  is  not  known  in  just  what  way  these  results  are 
produced,  whether  by  establishing  an  outflow  through  the  peri- 
choroidal space  or  through  the  canal  of  Schlem.  It  seems  probable, 
however,  that  the  good  results  which  occasionally  follow  this 
procedure  are  due  to  freeing  the  angle  of  the  anterior  chamber, 
and  not  to  permanent  choroidal  detachment. 

Excision  and  Trepanation,  or  Trephination,  of  the  Sclera. 
Sclerectomy. — Removal  of  a  portion  of  the  sclera  was  first  under- 
taken for  cystoid  scars  or  staphyloma  consequent  upon  penetrating 
wounds.  Coccius,!  transfixed  the  center  of  the  tumor  wdth  a  fine 
Graefe  knife,  cutting  out  parallel  with  the  base,  held  the  lips  of  the  in- 
cision closed  with  a  tenaculum,  and  completed  the  excision  with  for- 
ceps and  scissors.  More  recently,  in  a  similar  case,  Fage-  incised  the 
overlying  conjunctiva,  put  three  catgut  sutures  through  the  base  of 
the  ectasia,  made  the  exsection,  as  did  Coccius,  and  then  tied  the 
sutures.  The  loss  of  vitreous  was  slight,  and  the  result  satisfactory. 
The  idea  of  first  placing  the  sutures  was  taken  from  the  Critchett 
operation  for  corneal  staphyloma.  Taylor,  Argyll-Robertson  and 
De  Wcckcr,  tried  trephining  the  sclera  in  absolute  glaucoma, 
but  had  few  imitators.  In  this  connection,  however,  it  may  be 
mentioned  that  Frohlich,^  of  Berlin,  reports  that,  in  four  out  of 
five  eyes  with  absolute  glaucoma,  and  that  were  as  hard  as  stone,  he 

'  Heilanstult  fur  armc  Augenkranke  zu  Leipzig,  1S70,  S.  35-36. 
2  Gaz.  des  hop.  de  Toulouse,  1894,  iS  aoQt. 
3K1.  Mbl.  f.  A.,  Mai,  1904. 


SCLERECTOMY  427 

had  succeeded,  by  trephination,  in  reducing  the  tension  to  normal 
or  subnormal,  ridding  them  entirely  of  inflammation,  and  in  per- 
manently relieving  llicm  of  ])ain.  He  proceeds  thus:  Cocain; 
incision  of  conjuncti\a  along  lower  border  of  externus,  and  along 
outer  border  of  inferioris,  extending  nearly  to  cornea,  where  they 
are  joined.  The  flap  is  raised  and  turned  back  toward  the 
equator.  \'on  Hijjpel's  trephine,  with  5  mm.  crown,  set  for 
the  thickness  of  sclera  only,  is  used  for  the  excision.  On 
removal  of  the  disk,  if  retina  and  choroid  are  not  sufficiently 
ruptured  by  vitreous,  they  may  be  punctured.  The  conjunctival 
flap  is  put  in  place  and  sutured.  The  scleral  wound  takes  care 
of  itself. 

Of  late  years  sclerectomy  has  been  extensively  employed  in 
glaucoma  (Chapter  XII),  and  to  some  extent  in  detachment  of  the 
retina.  Parinaud,i  put  a  needle,  tangent,  into  the  outer  portion  of 
the  sclera  over  the  center  of  the  detachment,  and  lifted  up  a  cone. 
Through  this,  and  parallel  with  its  base,  he  passed  a  Graefe  knife 
so  as  to  excise  an  ovoid  piece  4  or  5  mm.  in  diameter.  The  choroid 
should  not  be  injured.  The  choroid  could  be  punctured  afterward, 
and,  if  need  be,  the  puncture  repeated  after  7  or  8  days. 

A  bold  and  extensive  operation  of  sclerectomy  for  detachment 
outward  is  that  resorted  to  by  L.  Miiller.-  The  patient  was 
narcotized.  Temporary  resection  of  the  outer  wall  of  the  orbit 
by  Kronlein's  method.  Excision  of  the  orbital  periosteum,  exposure 
of  the  external  rectus,  and  the  inferior  obHque,  and  their  severance 
from  the  globe.  Excision  of  a  strip  of  sclera  10  mm.  ividc  by  20 
mm.  long,  extending  from  2  mm.  behind  the  attachment  of  the 
externus  to  the  posterior  pole.  Five  silk  sutures  inserted,  and 
all  without  the  sUghest  injury  to  the  choroid.  The  choroid  was 
punctured  and  the  threads  tied.  When  the  subretinal  fluid  ran  out. 
The  retina  immediately  became  reattached,  the  held  of  vision 
became  normal  except  for  a  small  central  scotoma,  and  the  sight, 
which  had  been  reduced  to  counting  fingers  in  lower  field,  rose  to 
lingers  at  3  meters. 

Galvano-puncture  has  been  tried  by  De  Wecker  and  others,  both 
for  detachment  of  the  retina  and  for  circumscribed  staphylomas  of 
the  sclera,  but  the  results  have  not  been  encouraging.  (See  Chapter 
on  "The  Surgical  Treatment  of  Detachment  of  the  Retina.") 

1  Bull,  de  la  soc.  franf.,  d'opht.,  1S84,  p.  77. 
-  Wiener  kl.  Woch.,  Apr.,  1903. 


428  OPERATIONS  UPON  THE  GLOBE 

SUTURING  SCLERAL  WOUNDS. 

Small  wounds,  and  even  pretty  extensive  ones  that  are  meridional, 
may  often  be  left  without  sutures,  simply  cleansed,  extruding  vitreous 
snipped  off,  and  the  conjunctiva  stitched  over  them.  But  if  the 
scleral  wound  inclines  to  gape,  it  should  be  sutured.  If  the  scleral 
and  the  conjunctival  wounds  correspond,  the  same  threads  may 
include  both;  if  they  do  not,  it  is  best  to  close  the  scleral  opening 
with  absorbable  sutures  and  the  conjunctival  with  silk.  Indeed, 
it  is  usually  deemed  best  to  see  to  it  that  the  two  openings  do  not  corre- 
spond, even  if  apiece  of  the  conjunctiva  constituting  one  lip  of  the 
wound  must  be  excised  to  avoid  coincidence.  The  wound  is 
not  only  freed  from  dirt  and  vitreous,  but  from  shreds  of  choroid 
and  retina,  should  these  be  present.  Double-armed,  interrupted 
sutures  are  preferable,  so  that  the  needle  can  be  introduced  from 
within  on  both  sides.  The  thread  should,  if  possible,  be  made 
to  include  only  the  outer  layers  of  the  sclera,  and  in  no  case  should 
the  uvea  and  retina  be  included  either  in  the  wound  or  in  the  sutures. 
The  thread  or  gut  should  be  very  tine  and  the  needles  of  exceptional 
sharpness. 

Fage/  gives  the  following  reasons  for  suturing  scleral  wounds: 

1.  The  prevention  of  deep  infection. 

2.  Holding  back  the  contents  of  the  globe. 

3.  The  avoidance  of  fistula,  cystoid  scar,  and  staphyloma. 

4.  The  resulting  scar  is  more  regular,  less  contracted,  and  conduces 
less  to  detachment  of  the  retina. 

5.  The  healing  process  is  shortened. 

Czermak-  makes  a  rule  of  suturing  all  scleral  wounds  that  exceed 
5  mm.  in  length.  Even  the  subconjunctival  ruptures  are  sought  out, 
trimmed  up,  and  sutured.  If  the  lens  has  escaped  beneath  the 
conjunctiva,  of  course  it  is  let  out. 

Francis'  Method  of  Closing  Scleral  Wounds. — To  obviate 
suturing  the  sclera  in  traumatisms  that  cause  openings  in  this  tunic, 
Francis,  of  Buffalo  {Trans.  Section  on  Oph.,  A.  M.A.,  1913)  conceived 
the  happy  idea  of  a])])lying,  to  their  closure,  the  principles  of  con- 
junctivo-plasty.  'Lhc  method  is  suitable  to  scleral  wounds  of  any 
shape  or  extent,  and  running  in  any  direction,  except  those  that  are 
near,  and  parallel  with,  the  cornea. 

Technic. — After  thorough  cleansing,  all  tags  are  trimmed  down. 

1  Ann.  d'ocul.,  cxii,  \i.  262,  1894. 

2  AugenilrztliclK'n  ( )i>c'rati()ncn,  ]>.  690. 


CLOSING    SCLERA    WOUNDS 


429 


presenting  ^•it^eous  clipped  and  the  wound  edges  made  ready  for 
coaptation.  By  means  of  a  squint  hook  the  conjunctiva,  on  all  sides 
of  the  lips  of  the  wound,  is  loosened  from  the  sclera.  Double  armed, 
fine  silk  sutures  are  employed,  one  or  two  on  either  side,  depending 
upon  the  size  of  the  wound.  The  needles  are  j)assed  through  the 
conjunctiva,  from  the  under  surface,  near  the  margin,  at  one  side  of 
the  opening  in  that  membrane.  The  needles  are  then  carried  for 
some  distance  beneath  the  conjunctiva  at  the  other  side  of  the  open- 
ing, passed  up  through  (Fig.  260),  and  the  thread  drawn  up  and 
firmly  tied.     The  result  is  to  draw  a  flap  of  sound  conjunctiva  snuglv 


Fig.  260. 
Figs.  260  and  261. 


Fig.  261. 
-Frances'  method  of  closing  scleral  woiuids 


over  the  scleral  wound.  The  surface  of  this  flap  is  carefully  abraded, 
as  to  the  epithelium,  by  gently  scraping  with  a  convex  scalpel.  The 
conjunctiva  at  the  other  side  of  the  opening  is  now  pulled  over  in  a 
flap,  and  stitched  down  in  the  opposite  direction  (Fig.  261).  Thus 
the  wound  is  covered  by  a  second  layer  of  conjunctiva,  and  corre- 
spondingly reinforced.  In  drawing  over  the  flaps  it  is  important 
that  the  thread  be  well  drawn  up,  and  firmly  knotted,  else  one  of  the 
most  important  features  of  this  operation  will  be  lacking,  namely, 
sufl&cient  traction  upon  the  globe  in  the  region  of  the  injury  to  bring, 
and  to  hold,  the  edges  of  the  scleral  wound  into  close  apposition. 
If  the  scleral  wound  is  of  such  a  size,  and  so  located,  that  the  operator 
deems  it  wise  to  suture  the  sclera  as  well,  this  should  be  done  before 
the  surrounding  conjunctiva  is  loosened.     As  these  sutures  are  to  be 


430 


OPERATIONS    UPON    THE    GLOBE 


buried  they  must  be  absorbable.  Here  the  surgeon  has  the  choice 
of  such  materials  as  silk-worm  or  catgut,  kangaroo,  and  rat-tail. 
The  latter  is  well  adapted  to  the  work  in  hand,  being  strong  and 
extremely  pliable.  The  last  quality  minimizes  the  size  of  the  stitch- 
canal.  The  sutures  are  lubricated  with  sterile  olive  oil,  or  paraffin- 
vaseline,  to  facilitate  the  sewing  and  to  insure  filling  of  the  stitch-canal 
with  an  impermeable,  aseptic  substance.  That  the  needles  must  be 
exceedingly  fine,  and  as  sharp  as  it  is  possible  to  make  them,  is  a  fore- 
gone conclusion.  They  are  made  to  penetrate  the  sclera  slantingly, 
and  to  emerge  in  the  edge  of  the  wound — not  to  go  clean  through. 

Francis  has  never  used  scleral  sutures  since  adopting  the  super- 
posed conjunctival  flap  procedure.  The  following  points  are  men- 
tioned in  favor  of  the  double  thickness  of  conjunctiva  as  compared 
with  the  single: 

1.  The  traction  exerted  by  the  two  flaps  holds  the  scleral  wound 
lips  in  firm  apposition. 

2.  The  resulting  scar  is  thicker,  firmer,  and  more  unyielding. 

3.  The  two  layers  of  sound  con- 
junctiva protect  the  contents  of 
the  globe  from  outside  infection. 

NiieP  has  contrived  a  most  in- 
genious and  effective  arrangement 
of  the  thread  for  closing  corneo- 
scleral ruptures,  as  well  as  for  the 
wound  left  after  the  removal  of  a 
cystoid  scar  in  that  locality.  The 
suture  is  double-armed.  One  needle 
is  quilted  into  the  sub-conjunctival 
tissue  for  a  distance  of  2  centimeters  at,  and  parallel  with,  the 
equator,  i.e.,  for  a  distance  of  i  centimeter  on  either  side  of  the 
meridian  of  the  wound.  The  threads  are  then  crossed  over 
the  center  of  the  wound,  and  each  needle  carried  beneath  the 
conjunctiva,  in  the  episclera,  close  to,  and  half-way  around  the 
cornea,  where  they  arc  brought  out  together  and  tied  (Fig.  262). 

EXENTERATION  OF  THE  SCLERA. 

(eviseratio  bulbi.) 

Seeing  tliat  this  operation  consists  in  making  an  opening  in  the 
front  wall  of  the  globe  and  the  removal  of  its  entire  contents,  the 
1  Ann.  d'ocul.,  .\cix,  1S8S,  p.  270. 


Fig   262. — Nuel's  suture. 


EXENTERATION 


431 


author  has  taken  the  liberty  of  classing  it  amon<^  the  oi^crations  ujK)n 
the  sclera.  In  this  way  it  can  better  be  kept  distinct  from  the 
operation  of  simple  incision  of  all  the  tunics  of  thejrloi)e;  that  has 
been  commonly  called  evisceration.  Indeed,  it  would  be  belter 
if  the  term  evisceration  were  dropped  from  the  mechcai  (Hcti(;naries 
altogether,  since  it  has  precisely  the  same  etymologic  significance  as 
exenteration,  and  is  the  preferable  word  in  common  parlance,  wliere 
exenteration  is  rare. 

About  a  century  ago,  Wardrop,  of  Edinburgh,  as  a  cure  for  the 
sympathetic  ophthalmia  of  horses,  advised  incision  of  the  cornea  of 
the  exciting  eye,  and  the  removal  of  the  lens  and  vitreous,  suggesting 
at  the  same  time  that  a  similar  procedure  might  be  applied  to  the 
human  eye.  The  first  to  put  the  suggestion  into  effect  was  Barton, ^ 
who  employed  it  for  the  removal  of  fragments  of  copper  from  the  eye. 
As  has  already  been  stated  on  page  402,  De  Wecker,  about  1883, 
added  exenteration  to  his  tobacco-pouch  modification  of  Critchett's 
ablation.  Frohlich,-  in  1881,  "removed  the  front  section  of  the 
globe  and  scooped  out  the  contents  of  the  scleral  capsule,"  with 
the  hope  of  escaping  the  grave  consequences  that  sometimes  follow 
enucleation.  Alfred  Graefe^  adopted  exenteration  for  most  cases 
for  which  formerly  enucleation  had  been  practiced.  He  excepted 
those  in  which  there  was,  or  threatened  soon  to  be,  sympathetic 
ophthalmia.  This  surgeon  was  the  tirst  to  plan  for  the  operation  a 
definite  technic,  the  main  points  of  which  are  as  follows:  The 
upper  lid  is  held  up  by  an  assistant  with  a  Desmarres  retractor. 
Supposing  it  to  be  the  right  eye,  the  operator  grasps  the  conjunctiva 
at  the  external  corneal  limbus  with  fixation  forceps,  while  the  as- 
sistant does  the  same  only  5  mm.  further  back  in  the  horizontal 
meridian.  The  intervening  tissue  is  put  upon  the  stretch,  but 
without  pressure  upon  the  globe,  and  with  a  convex  scalpel  a 
small  vertical  incision  is  made,  close  up  to  the  forward  forceps, 
carefully  carried  in  until  the  blackness  of  the  ciliary  body  shows. 
Now,  with  delicate,  blunt-pointed  scissors,  the  incision  is  extended 
between  the  sclera  and  the  cornea  till  the  two  meet  at  the  corre- 
sponding point  on  the  opposite  side.  Here  Bunge's  exenteration 
curet  is  inserted  between  sclera  and  uvea,  convex  side  out,  and  the 
two  tunics  separated,  cutting  in  succession  the  vorticose  veins,  the 
ciliary  arteries  and  nerves,  and  finally  the  neck  of  the  optic  nerve- 

1  Crampton  Med.  Gaz.,  London,  1837. 

2  Klin.  .Mbl.  F.  S.,  1881,  S.  30. 

3  Tagb.  der  57.  Vers.  Deutsch.  Naturf.  u.  Aerzte,  Magdeburg,  1SS4. 


432  OPERATIONS  UPON  THE  GLOBE 

head.  Having  seen  that  only  the  bare  sclera  remains,  the  cavity  is 
washed  and  the  opening  closed  by  from  3  to  5  vertical  sutures  that 
include  both  conjunctiva  and  sclera. 

The  reaction  after  this  operation  is  usually  considerable,  the 
chief  features  being  chemosis,  particularly  of  the  lower  half  of  the 
conjunctiva,  and  swelling  of  the  upper  lid.  The  chemotic  mem- 
brane often  projects  beyond  the  palpebral  fissure,  and  is  very  slow 
to  disappear.  There  is,  moreover,  needless  sacrifice  of  the  outer 
wall  of  the  sclera.  To  obviate  this,  Gifford,  of  Omaha,  quite 
properly,  omitted  excision  of  the  cornea,  making  the  exenteration 
through  a  simple  horizontal  incision,  thus  causing  less  reaction,  and 
securing  a  more  ample  stump. 

The  writer,  who  had  previously  made  only  the  De  Wecker  opera- 
tion (described  in  chapter  on  Anterior  Staphyloma),  seeing  the 
advantages  of  Gifford's  method,  adopted  it.  He  had  noticed, 
however,  that  the  stump,  after  all  methods  where  the  long  axis  of 
the  wound  lay  in  the  horizontal  meridian,  was  always  characterized 
by  a  deep  cleft,  lying  in  the  same  direction  and  reaching  far  back 
into  the  sclera  on  both  sides — really  a  folding  of  the  globe  upon 
itself,  causing  it  to  resemble  a  grain  of  barley.  This  determined 
him  to  make  the  opening  vertical,  though  still,  like  Gifford,  without 
the  excision  of  cornea,  except  in  cases  of  anterior  staphyloma,  when 
just  enough  is  removed  to  cause  adequate  flattening.  A  long, 
narrow,  vertical,  pointed  ellipse  is  ample  for  even  a  pronounced 
staphyloma.  In  either  case,  the  ends  of  the  incision  or  the  points 
of  the  ellipse  are  extended  sufiEiciently  far  into  the  ciliary  region  to 
give  ingress  for  instruments  and  small  spindle-shaped  cotton 
sponges.  The  operator  grasps  the  center  of  the  wound  on  one 
side  with  fixation  forceps  (without  catch);  an  assistant  does  the 
same  on  the  other,  and  in  such  a  way  that,  by  rotating  the  instru- 
ments, the  cornea  and  sclera  can  be  rolled  back  like  the  turning  up  of 
a  sleeve  (Fig.  263).  A  knife  of  special  design,  first  described  in  the 
Ophthalmic  Record,  July,  1905,  is  used  to  dissect  the  choroid  from 
the  sclera  (Plate  II,  No.  39).  The  blade,  ivhich  is  not  ovcrsharp, 
is  double-edged,  curved  on  the  flat  so  as  to  lit  into  the  scleral 
cavity,  and  has  a  rounded  extremity.  This  serves  to  sever  the  roots 
of  the  iris,  the  ciliary  body,  the  veins,  arteries,  and  nerves,  but  for 
fear  of  perforating  with  the  knife  when  it  comes  to  the  optic  nerve 
the  assistant  takes  both  forceps,  the  surgeon  holds  choroid  and  retina 
witli  broad-jawed  forceps,  and  cuts  the  tissues  at  the  limina  cribrosa 


EXENTERATION 


433 


with  small,  curved,  bIunt-i)ointC(l  scissors,  which  c()mj)letes  the 
exenteration.  Co})ious  irrigation  of  the  cavity  with  hot  sublimate 
solution,  I-2000,  is  now  used,  for  the  double  purpose  of  checking 
the  hemorrhage,  so  that  one  may  see  that  every  vestige  of  the  con- 


FiG.  263. — Beard  method  of  exenteration. 

tents  has  been  removed,  and  of  antisepsis.  Any  relics  of  the  uvea 
are  scraped  away  with  the  knife  or  sharp  curet.  A  small  flattish 
curet  with  finely  serrated  edge  is  best.  Having  been  assured  that 
nothing  is  left  behind,  the  opening  is  immediately  closed  by  several 
28 


434  OPERATIONS  UPON  THE  GLOBE 

horizontal  silk  sutures,  allowing  the  oozing  blood  to  iill  the  scleral 
capsule  if  it  will.  No  attempt  is  made  to  stop  the  moderate  oozing 
of  blood,  but  rather  it  is  encouraged,  by  mild  curetment  if  necessary, 
so  as  to  insure  a  clot  of  sut^cient  size  to  fill  the  scleral  capsule,  with 
the  view  to  its  becoming  organized,  thus  adding  to  the  efficiency  of 
the  stump.  The  eye  is  bandaged  in  the  usual  way.  For  some 
reason  there  seems  to  be  even  less  chemosis  following  the  vertical 
incision  than  the  horizontal,  and  the  cleft,  just  alluded  to,  does  not 
ensue.  In  case  after  case  the  parts  involved  have  remained  abso- 
lutely quiet.  The  sutures  are  removed  after  3  or  4  days.  Union  is 
usually  by  first  intention.  If  it  is  not,  a  small  round  hole  may 
appear,  which  slowly  closes.     I  have  never  seen  any  harm  come  of  it. 

There  is  pretty  free  bleeding  wdiile  the  separation  of  the  choroid 
is  going  on,  but  it  does  not  materially  interfere.  Of  course,  the  lens 
and  the  vitreous  escape  as  soon  as  the  globe  is  well  open. 

Exenteration  is  indicated  in  all  instances  where  it  has  been  the 
custom  to  make  enucleation,  save  where  exists  sympathetic  ophthal- 
mia, a  neoplasm  of  the  globe,  or  phthistis  so  advanced  that  only  a 
tiny,  shapeless  button  remains.  I  would  not  even  except  those  in 
which  sympathetic  trouble  is  impending,  nor  would  I  those  in  which 
it  is  already  present  but  for  the  popular  prejudice  of  the  profession. 
Yet  more,  I  would,  and  do,  add  all  the  cases  of  total  staphyloma  of 
the  cornea.  For,  as  before  stated,  ablation  of  the  staphyloma  ful- 
fills none  of  the  indications,  or,  if  any,  does  it  poorly,  while  exentera- 
tion meets  them  all  and  meets  them  well.  For  all  but  the  cases 
mentioned  as  exceptions,  it  is  not  only  a  much  better  pro- 
cedure than  enucleation,  in  view  of  the  objects  desired,  but  all  the 
evidence  points  to  its  being  a  safer  one.  All  those  parts  that  have 
been  deemed  a  menace  to  the  fellow  eye  are  as  effectually  gotten  rid 
of  as  by  enucleation.  As  to  the  growth  of  new  nerve  structures 
within  the  exenterated  sclera,  discovered  by  Forget,^  and  mentioned 
as  a  possible  source  of  discomfort,  if  not  of  danger,  it  would  seem 
quite  as  easy  for  this  to  occur  within  the  capsular  envelope  which 
remains  after  enucleation.  As  to  the  conditions  for  the  wearing  of 
a  prothesis,  they  are  vastly  more  favorable  where  the  walls  of  the 
globe  are  left  intact  than  where  they  have  been  taken  away  entirely. 
Made  according  to  the  principles  just  given,  there  being  no  inflam- 
matory reaction,  not  only  is  an  extra  large  stump  afliorded  for 
filling  out  the  orbit  and  giving  to  llie  artificial  shell  something  like 

•  Arcli.  d'opht.,  t.  xii,  1892,  p.  693. 


ARTIFICIAL    VITREOl^S  4^5 

suitable  prominence,  bul  the  muscles  are  all  left  willi  their  original 
attachments,  and  in  their  normal  relations,  so  that  its  mo\ements  are 
reas()nal)ly  exlensi\e  and  natural. 

The  Substitution  of  an  Artificial  Vitreous  Body.  In  spite  of 
the  greatest  care  in,  and  of  only  a  minimum  of  reaction  after,  the 
operation  of  exenteration,  the  shrinkage  of  the  stump  becomes,  in 
time,  considerable,  and,  in  consequence,  its  motility  becomes  much 
restricted.  With  the  \-ie\v  to  supplying  a  larger  and  more  mo\able 
permanent  stump,  ■Nlules.^  of  Glasgow,  conceived  the  idea  of  placing 
in  the  exenterated  sclera  a  hollow  glass  ball.  Encouraged  by  the 
immediate  results  of  the  procedure,  ophthalmic  surgeons  every- 
where followed  Mules'  example,  and  a  few  became  enthusiastic  over 
it.  After  a  few  years,  however,  even  those  who  had  in  the  begin- 
ning been  most  captivated  grew  less  ardent.  Too  often  the  ball 
refused  to  remain  im])risoncd.  The  measure  was  mostly  abandoned. 
Some,  who  had  been  won  by  the  really  great  plausibility  of  the 
method,  began  to  cast  about  for  spheres  of  dilTerent  substances 
and  of  different  construction.  Kuhnt,  for  example,  tried  silver; 
Keal,  gold;  Bryant  (of  Omaha),  fenestrated  aluminum,  etc.  The 
material  that  seems,  at  the  present  time,  to  promise  most  in  this 
connection,  is  paraffin.  Living  tissue  will  bear  incori)oration  with 
this  substance  more  tolerantly  than  with  any  other  thus  far  in- 
troduced. There  are  two  ways  of  filling  the  sclera  with  iJaraflin: 
I.  By  closing  the  opening  in  the  globe  and  overlying  membranes  by 
a  common  purse-string  suture,  or  by  suturing  them  separately; 
then  injecting  into  the  scleral  cavity  the  melted  jjaratYin.  This  is 
the  method  of  Brockaert,  also  that  very  successfully  followed  by 
Ramsay,  of  Glasgow.  2.  By  fashioning  the  sphere  of  hard  paraffin 
beforehand,  and  inserting  it  in  the  cavity  after  the  same  manner  in 
which  Mules  employed  the  original  ball  of  glass.  This  is  the  mode 
recommended  by  Oatman,  of  New  York,  and  is  probably  the  more 
desirable  as  to  precision.  Balls  of  paraffin  having  a  high  melting- 
point — 140  degrees  and  over — are  prepared  by  fusing,  filtering, 
and  sterilizing,  then  rolling,  while  yet  warm  and  plastic,  with  the 
protection  of  rubber  gloves.  In  size,  they  should  vary  from  a 
diameter  of  12  mm.  to  that  of  18  mm.,  according  to  the  capacity 
of  the  sclera  they  are  to  occupy.  They  are  kept  ready  for  use  in  a 
glass  jar  filled  with  a  5%  solution  of  formaldehyd.  Before  being 
placed  within  the  sclera,  the  ball  is  rinsed  withasolution  of  bichlorid, 

'Trans.  Ophthahnolog.  Society,  1885,  vol.  v,  p.  200. 


436  OPERATIONS  UPON  THE  GLOBE 

1-2000.  If  the  opening  in  the  sclera  is  sufficiently  large,  the  ball 
may  be  put  in  place  with  ordinary  dressing  forceps.  Usually, 
however,  it  will  be  found  more  convenient  to  introduce  it  with  the 
aid  of  the  Mules  inserter  (Plate  \'III,  No.  89).  All  bleeding  is 
previously  stopped  by  means  of  hot  bichlorid  irrigation.  The 
scleral  opening  is  closed  over  the  sphere  in  the  vertical  sense,  i.e., 
by  silk  sutures,  placed  horizontally.  If  the  conjunctiva  has  been 
first  incised  around  the  cornea,  chromicized  catgut  is  used  to  close 
the  sclera  in  the  manner  just  stated.  The  conjunctival  opening  is 
then  drawn  together  in  the  horizontal  sense — or,  by  interrupted  silk 
sutures  placed  vertically.  Purse-string  or  tobacco-pouch  sutures 
are  not  admissible.  The  eye  is  dressed  in  the  usual  way  and  left 
for  48  hours  before  redressing.  Not  only  is  the  most  rigid  asepsis 
necessary,  but  it  is  indispensable  that  the  character  of  the  coapted 
lips  of  the  scleral  opening  is  such  as  to  insure  primary  union,  else 
the  ball  will  surely  be  extruded.  Whereas,  after  exenteration  with- 
out substitution  of  the  artificial  vitreous,  it  matters  but  little 
whether  the  adhesion  be  prompt  or  delayed. 

Amputation  of  the  Anterior  Segment  of  the  Globe. — Guerin, 
Saint-Ives,  and  Heister,  in  the  i8th  century,  advised,  when  practi- 
cable, to  remove  the  front  half  of  the  eyeball,  instead  of  making  a 
complete  excision  of  the  globe  in  order  to  facilitate  the  wearing  of  a 
prothesis.  The  procedure  was  considered  applicable  to  cases  of 
malignant  tumors  confined  to  the  section  to  be  discarded  and  to 
total  staphyloma  of  the  cornea.  The  operation  consisted  in  the 
ablation  of  the  cornea,  the  iris,  and  the  cihary  zone,  leaving  intact  the 
insertions  of  the  straight  muscles  with  their  capsular  coverings. 
The  scleral  incision  should  be  started  with  a  cataract  knife,  and 
finished  with  blunt-pointed  scissors.  The  remainder  of  the  uveal 
tract,  with  the  retina,  is  then  to  be  curetted  out,  and  the  cavity  kept 
packed  with  antiseptic  gauze  until  healing  occurs.  If  the  operation 
were  done  to-day,  the  scleral  opening  would  doubtless  be  closed, 
at  least  ])artially,  by  suturing. 

Amputation  of  the  Posterior  Segment  of  the  Globe. — Nicati.^ 
])erforms  this  operation  as  follows:  A  horizontal  (or  vertical)  in- 
cision is  made  into  the  conjunctiva  on  the  inner  side  of  the  globe. 
The  internus  is  seized,  divided  through  its  tendon,  and  guarded  by  a 
catgut  suture,  which  is  passed  through  the  tendon  and  the  con- 
junctiva.    The  capsule  is  separated  above  and  below  and  the  optic 

'  Archives  d'oiilithalmolngie,  June,  1003. 


IRIDOTOMY 


437 


nerve  is  sectioned  in  the  ordinary  manner.  The  posterior  i)ole  of 
the  eyeball  is  caught  by  a  tenaculum  and  drawn  forward.  The 
obliques  are  detached  from  it  and  it  is  drawn  through  the  con- 
junctival opening,  after  which  the  posterior  portion  of  the  globe  is 
exsected  up  to  the  insertions  of  the  rectus  muscles.  The  tendon  of 
the  adductor  is  secured  to  its  stump,  and  the  conjunctival  opening  is 
closed.  An  accumulation  of  blood  behind  forces  the  cornea  forward, 
but  this  is  removed  by  compression  and  absorption.  Nicati  claims 
that  the  convalescence  is  more  rapid  than  after  enucleation,  and  the 
results  are  an  excellent  stump  with  the  conjunctiva  and  cornea 
entire.  He  asserts,  also,  that  sympathetic  ophthalmia  is  avoided, 
but  th  s  must  be  open  to  question,  seeing  that  there  is  no  provision 
for  the  removal  of  the  anterior  portion  of  the  uvea.  Moreover,  the 
operation  is  difficult,  and  involves  dangers  of  deep  infection  not  in- 
curred in  those  previously  described. 

None  of  these  operations  possess  that  virtue,  dear  to  the  heart  of 
the  pathologist,  of  preserving  a  perfect  specimen  for  the  laboratory 
as  does  enucleation. 

OPERATIONS  UPON  THE  IRIS. 

IRIDOTOMY — IRITOMY. 

This  has  for  its  object  the  making  of  an  opening  or  pupil  in  an 
otherwise  imperforate  iris  by  means  of  a  simple  incision,  and  of  the 
several  operations  made  upon  this  membrane  it  is  the  oldest.  The 
idea  originated  with  Thomas  Woolhouse,i  of  London,  who  pro- 
posed, in  case  of  loss  of  sight  from  posterior  synechia,  to  tear  the 
iris  asunder  from  behind,  with  a  needle  entered  through  the  sclera  as 
if  for  couching  (scleronyxis) .  Whether  or  not  he  made  the  opera- 
tion, is  not  known.  It  is  known,  however,  that  17  years  later, 
another  English  surgeon,  and  a  pupil  of  Woolhouse,  William 
Cheselden,2  put  the  idea  of  Woolhouse  into  practice  for  closure  of 
the  pupil  in  eyes  where  cataract  had  been  depressed.  Heuerman,^ 
of  Copenhagen,  changed  the  point  of  entrance  to  the  cornea. 
Guerin,4  and  Janin,'^  observ.ng  that  the  needle  of  Cheselden  tore, 
rather  than  cut,  the  iris,  first  made  a  corneal  incision,  then  made 
the  iridotomy  with  small  curved  scissors,  one  blade  of  which  was 

1  Exp^r.  de  differentes  oper.  aux  yeux,  Paris,  1711. 

2  Philosoph.  Transactions,  1728. 

3  Abhandlungen  v.  d.  Chir.  Operationen,  Kopenhagen,  1756. 

*  Traits  sur  les  mal.  des  yeux,  Lyon,  176Q. 

*  Mem.  et  observations  sur  I'oeil,  Lyon,  1772. 


438  OPERATIONS  UPON  THE  GLOBE 

pointed  and  the  other  blunt.  Guerin  made  a  crucial  incision  in  the 
iris,  Janin,  a  bow-shaped.  Maunior,i  in  cases  of  atresia  of  the  pupil, 
with  atrophy  of  the  iris,  thrust  the  pointed  blade  of  the  scissors 
behind  the  iris  in  two  places,  making  a  V-shaped  incision,  base 
peripheral.  The  inclosed  piece  was  not  excised,  but  merely  al- 
lowed to  retract.  Bowman,  ^  of  London,  who  was,  from  first  to 
last,  an  advocate  of  iridotomy,  invented  scissors  whose  points 
served  as  a  keratome,  whereby  the  operation  could  be  accomplished 
with  a  single  instrument.  The  operation  of  iridectomy  having,  in 
the  meantime,  become  popularized,  it  for  a  time  largely  superseded 
that  of  iridotomy.  The  latter  w^as  again  brought  forward  by  von 
Graefe,  in  1869,  as  an  efficient  measure  for  those  forlorn  cases  of 
closure  of  the  pupil,  atrophy  of  the  iris,  and  flattening  of  the  an- 
terior segment  of  the  globe  from  iridocystitis  following  a  cataract 
extraction.  \'on  Graefe  at  first  employed  the  method  of  Heuer- 
mann.  The  matter  was  taken  up  with  a  will  by  ophthalmic  sur- 
geons, having  been  specially  pushed  by  Bowman  and  De  Wecker. 
The  last-mentioned  brought  to  bear  all  his  wonted  ingenuity,  skill, 
and  industry,  refining  and  elaborating  the  procedure  until  he  not 
only  evolved  for  it  a  system  of  technic  that  has  remained  standard, 
but  devised  also  kindred  measures  and  the  rules  governing  them 
for  cases  not  adapted  to  iridotomy.  Conspicuous  among  these  were 
his  irito-edomy  and  irito-dialysis.  His  labors  in  this  line  included 
the  invention  of  several  instruments,  the  most  valuable  of  which  is 
his  forceps-scissors,  wdiich  embodies  the  principle  of  the  Liebreich 
iris  forceps,  and  which,  in  some  form,  is  still  the  favorite  instru- 
ment for  all  sections  of  the  iris.  The  corneal  incision  he  made  with 
a  stop-lance,  similar  to  the  paracentesis  knife  of  Desmarres.  The 
advantage  of  this  instrument  over  the  ordinary  keratome  is  that  there 
is  no  danger  of  penetrating  too  deep,  or  even,  as  could  happen,  to  the 
extent  of  having  the  entire  blade  enter  the  anterior  chamber. 

De  Wecker's  Methods  of  Iridotomy. — In  cases  of  occlusion  of 
the  pupil,  with  presence  of  the  crystalline,  he  made  a  corneal  in- 
cision opi^osite  that  part  of  the  iris  zone  where  the  pupillary  border 
was  least  adherent.  Through  this  he  inserted,  closed,  the  blades 
of  a  ])air  oi  his  scissors,  both  points  of  which  were  blunted.  When 
approaching  the  puj)il,  the  blades  were  slightly  opened,  one  of  them 
passed  behind  the  iris,  taking  care  not  to  wound  the  lens  capsule,  the 

1  M6m.  sur  Toper,  de  la  pupille  artif.,  181 2. 

2  Med.  Times  and  Gazette,  1852,  p.  35. 


IRITO-ECTOMY 


439 


blades  still  wider  opened  and  puslied  further  in.  a  cut  made,  the  in- 
strument slitj;htly  rotated  and  another  cut  made,  thus  loosening  a 
pointed  llap,  apex  inward,  like  that  of  Maunior  (Figs.  264  and  265). 
For  complete  atresia  of  the  iris  in  aphacic  eyes  either  the  point  of 
the  keratome,  while  engaged  in  the  corneal  incision,  was  made  to 
pierce  the  iris  at  a  suitable  spot  for  inserting  the  scissors,  or  else  the 
operator  used  a  pair  of  scissors,  one  blade  of  which  was  sharp- 
pointed,  and  with  this  the  membrane  was  transfixed.  The  cut 
could  be  single  or  double. 

De  Wecker's  irito-ectomy  and  irito-dialysis  are  applicable 
only  to  cases  of  closure  of  the  pupil  where  the  lens  is  absent.  Irito- 
ectomy  is  a  combination  of  iridotomy  and  iridectomy,  or,  in  other 
words,  intraocular  iridectomy.  In  this  operation  the  corneal 
incision  and  the  primary  incision  of  the  iris  are  made  simultaneously 


Fig.  264.^11 


Fig.  265. — Result. 


and  with  the  same  knife.  Where  a  relati\-ely  small  opening  in  the 
iris  is  desired,  an  iridectomy  knife  is  entered  at  the  limbus  toward 
w^hich  the  iris  is  drawn,  and  a  corneal  incision  made  as  if  for  iridec- 
tomy, except  that  the  blade  is  directed  backward  at  such  an  angle 
as  to  make  a  corresponding  cut  in  the  iris  close  to  its  periphery. 
The  blunt-pointed  forceps-scissors  are  then  put  in  at  one  extremity 
of  the  wound,  one  blade  passing  behind  the  iris,  and  a  snip  is  made 
toward  the  normal  pupil  center.  The  scissors  are  withdrawn,  put 
in  at  the  other  extremity  of  the  corneal  wound,  and  a  similar  snip 
made,  the  two  cuts  meeting,  wdiereby  is  completed  the  excision  of 
a  triangle  of  iris.  If  a  larger  iridectomy  is  wanted,  a  large,  linear, 
corneal  incision,  which  includes  the  iris,  is  made  with  a  Graefe 
knife  near  the  limbus  opposite  the  point  toward  which  the  pupil  is 
drawn,  and  the  triangular  piece  cut,  as  just  described.  Here,  how- 
ever, before  making  the  final  snip  to  complete  the  section,  iris  forceps 


440  OPERATIONS  UPON  THE  GLOBE 

is  introduced  at  the  other  end  of  the  corneal  incision  for  the  double 
purpose  of  holding  the  piece  for  the  cut  and  removing  it  from  the 
anterior  chamber  when  severed. 

In  order  to  facilitate  the  making  of  the  iris  incision  when  it  is 
made  one  step  with  that  of  the  corneal,  as  soon  as  the  point  of  the 
knife  is  well  within  the  eye  it  is  tilted  so  as  to  pry  open  the  cut  and 
evacuate  the  anterior  chamber,  which  causes  the  iris  to  advance 
close  to  the  cornea. 

The  advantage  of  such  (scissors)  operations  is  that  they  insure  a 
minimum  of  traction  on  the  root  of  the  iris  and  upon  the  ciliary 
body,  hence  it  suffers  less  traumatism  and  remains  more  quiet 
afterward.  This  is  not  true  of  those  iridotomies  made  with  needle 
or  knife  alone  except  in  instances  where  the  instrument  can  be 
made  to  cut.  Usually,  after  the  point  of  the  knife  or  knife-needle 
has  passed  through  the  iris,  all  cutting  ceases — it  is  merely  tearing. 
The  chief  objections  to  the  scissors,  or  knife  and  scissors  methods, 
are  the  too  free  incisions  in  the  globe,  often  lying  wholly  in  the  clear 
cornea,  entailing  undue  loss  of  aqueous  and  vitreous,  thus  causing 
other  dangers,  and  that  they  are,  on  the  whole,  complicated  and 
difficult. 

Irito-dialysis. — DeWecker  considered  a  measure  of  last  resort 
in  those  troublesome  cases  where,  in  addition  to  closure  of  the  pupil, 
there  existed  adhesions  between  cornea  and  iris,  and  especially  in 
such  of  these  as  had  not  been  benefited  by  other  means.  It  consisted 
in  making  the  primary  combined  incision  with  keratome  or  stop- 
knife  near  the  center  of  the  cornea,  and  facing  that  segment  of 
the  periphery  where  the  iris  was  most  nearly  normal.  The  intro- 
duction of  the  blunt-pointed  scissors,  one  blade  behind  the  iris, 
and  making  two  diverging  cuts,  one  from  each  end  of  the  first  iris 
incision,  and  reaching  to  the  outer  border  of  the  iris.  The  interven- 
ing segment  of  iris  was  then  forcibly  torn  from  its  fastening  and 
extracted  by  means  of  strong  straight  forceps.  This  procedure 
was  naturally  often  productive  of  very  unpleasant  reaction. 

Modifications. — A  few  of  the  many  modes  of  performing  the 
foregoing  o])crations  will  be  here  mentioned. 

Iridotomy. — Milles^  and  Nacati,-  instead  of  making  the  corneal 
incision  at  right  angles  to  the  course  of  the  iris  fibres,  recommend 
making  it  parallel  therewith  in  order  the  better  to  direct  the  cut 

1  Royal  Oph.  Hosp.  Rep.,  x,  3,  1882,  p.  403. 
*  Ann.  d'opht.,  iii,  1883,  p.  403. 


IRIDOTOMY  441 

of  the  scissors  across  said  fibres.  SichcP  and  Schcrk^  reverted 
to  the  Heuermann-Graefc  method,  but  each  with  a  knife,  or  rather 
a  knife-needle,  of  his  own  invention.  Sichel's  instrument  was 
something  like  his  discission  needle,  only  the  tiny  blade,  instead 
of  being  curved,  was  straight,  and  resembled  in  form  the  Zehendcr 
cataract  knife.  The  Knapp  knife-needle  does  not  differ  ma- 
terially from  the  iridotome  of  Sichel.  Scherk's  was  compli- 
cated, having  on  the  handle  an  attachment  whereby  the  little 
lance-like  blade  could  be  given  a  sawing  motion. 

Of  all  forms  of  simple  iridotomy  I  prefer  that  of  Gayet.'  This 
is  essentially  the  same  as  that  given  in  the  chapter  on  "  Discission 
of  Secondary  Cataract"  as  the  method  of  Pagenstecher.  Gayet 
used  an  ordinary  Graefe  knife,  punctured  the  anterior  chamber  at 
the  base  of  the  cornea,  the  flat  of  the  blade  parallel  with  the  plane 
of  the  iris;  the  handle  was  then  slightly  raised,  the  iris  pierced  and 
incised,  without  enlarging  the  corneal  wound,  by  making  the  blade 
describe  a  small  arc.  Now,  it  is  next  to  impossible  to  make  a 
clean  cut  of  the  iris  or  of  a  membranous  cataract  (and  discission  is 
but  a  phase  of  iridotomy)  by  mere  pressure  of  the  edge  of  the  knife, 
no  matter  how  keen  it  may  be.  The  membrane  will  only  be  pushed 
along  and  torn.  But  a  little  sawing  motion  imparted  to  the  blade, 
however  slight,  will  cause  it  to  cut.  In  sawing  with  a  sharp  knife, 
it  is  difficult  to  prevent  harmful  wounding  or  extension  at  the 
point  where  it  engages  the  cornea.  To  avoid  this,  I  have  the  edges 
of  the  Graefe  knives,  which  are  used  both  for  discission  and  iridotomy, 
made  dull  and  smooth,  for  the  first  two-thirds  of  the  distance  and 
sharp  and  wiry  for  the  last,  or  end,  third.  The  operation  can  be 
done  in  this  way  without  any  loss  of  aqueous,  which  cannot  be 
said  of  the  knife-needle  method.  This  form  of  knife,  particularly 
if  the  blade  be  somewhat  smaller  in  every  way  than  that  of  the 
regulation  cataract  knife,  is  one  of  the  most  manageable  of  instru- 
ments. The  old  and  worn-down  Graefe  knives  can  be  thus  utilized. 
The  corneal  wound  is  insignificant  and,  being  in  the  vascular  zone, 
heals  at  once.  If  one  is  careful  to  make  the  iris  incision  at  right 
angles  to  the  direction  of  greatest  strain  of  the  fibres,  and  no  inflamma- 
tion of  the  membrane  follows,  a  permanent  round  or  elliptical  pupil 
will  result.     Should  the  iris  tissue  be  such  as  not  to  retract,  or  should 

1  Klin.  Mbl.  F.  S.,  XV,  1877,  S.  273. 

2  Klin.  Mbl.  F.  S.,  xxi,  1883,  S.  315. 

3  Prog,  m^.,  No.  35,  1880. 


442 


OPERATIONS    UPON    THE    GLOBE 


the  new    pupil   close    from   iritis,  there  is  still    time  to  resort   to 
irito-ectomy. 

Modifications  of  Irito-ectomy.— Tyrcll's  blunt-hook  method. 
The  primary  corneal  incision  is  made  with  a  lance-keratome, 
the  blade  of  which  is  made  to  traverse  the  anterior  chamber  to  a 
point  just  beyond  the  limits  of  the  proposed  pupil.  Here  it  is 
passed  through  the  iris,  when,  by  a  sort  of  rocking  motion,  the  cut 
is  enlarged.  The  knife  is  withdrawn,  the  blunt  iris  hook  is  inserted, 
flatwise,  at  the  corneal  wound,  pushed  across  to  the  iris  wound, 
given  a  quarter  turn  so  as  to  catch  the  hither  edge  of  the  cut,  the 
membrarie  drawn  a  little  way  outside  of  the  corneal  incision,  and 
a  small  piece  cut  off  with  scissors.  This  measure  is  less  complex  and 
difficult  than  the  intraocular  scissors  methods,  and  done  with  less 
dragging  upon  the  iris  than  is  the  operation  of  irito-dialysis.  It  is 
the  same  as  the  procedure  described  by  Knapp^  as  "irido-cystec- 
tomy."  The  writer  was  led  to  adopt  it  for  many  cases  of  membranous 
cataract  and  closure  of  the  pupil  after  extraction  by  the  splendid 
results  he  had  seen  obtained  for  the  procedure  at  the  hands  of  the 
late  Cornelius  R.  Agnew,  of  New  York. 


Fig.  266.- — Incisions. 


suit. 


To  obviate  traction  upon  the  iris,  Abadie-  devised  an  ingenious 
mode  for  irito-ectomy,  by  which  he  obtained  a  quadrilateral  pupil. 
Two  parallel  incisions  of  the  cornea,  5  or  6  mm.  apart,  made  with 
the  lance-keratome,  the  first  one  smaller,  the  second  larger  and 
made  to  pierce  and  incise  the  iris  to  form  one  side  of  the  opening. 
Introduction  of  tiny  forceps-scissors  at  the  larger,  and  extending 
the  iris  cut  in  this  form  (Fig.  266).  Withdrawing  the  flap  with  iris 
forceps  or  hook  at  the  smaller  corneal  incision,  and  cutting  it 
off  its  base  (Fig.  267). 

1  Norris  and  Oliver's  System,  p.  792. 

2  Ann.  d'ocul.,  1888,  p.  261. 


CORKLYSIS  443 

OPKR.VrJOXS  FOR  SYNECHIA. 

CoRELYSis.     Anterior  and  Posterior 
Synechiotomy. 
These  ojjcralions  liave  for  their  object: 

1.  The  cure  of  the  defect  itself,  i.e.,  the  severance  of  the  iris  from 
its  attachment. 

2.  The  affording  of  rehef  from  the  irritating  effects  of  the  synechia. 
The  lirst  constitutes  true  synechiotomy.     In  the  second  instance, 

the  breaking  up  of  the  adhesions  is  apt  to  be  but  partial  and  incidental. 

As  the  synechia  is  said  to  be  posterior  or  anterior,  according  as 
it  concerns  union  of  the  iris  with  the  crystalline  lens  or  with  the 
cornea,  so  is  the  synechiotomy  posterior  or  anterior. 

Corelysis  is  the  term  that  distinguishes  posterior  synechiotomy, 
Wenzel,  of  Paris  and  London,  in  the  latter  part  of  the  i8th  century, 
was  the  first  to  practise  posterior  corelysis.  He  broke  the  adhesions 
with  a  needle  introduced  by  way  of  the  anterior  chamber,  and  the 
measure  was  resorted  to  only  when  the  lens  was  cataractous.  A 
little  later,  Beer  did  the  same  by  means  of  a  tiny  sharp  hook.  The 
first  to  make  the  operation  in  cases  where  the  lens  retained  its 
transparency  was  Streatfeild,^  of  London,  at  whose  hands  the 
procedure  attained  a  degree  of  popularity.  He  first  made  an 
incision  with  the  keratome,  then  attacked  the  synechia  with  an 
instrument  that  he  called  a  spatula,  but  that  was,  in  reality,  a  tiny 
knife  bearing  at  the  extremity  of  the  blade  a  blunt  hook.  Weber, ^ 
of  Darmstadt,  also  devised  a  method  and  a  synechitome,  the  latter 
being  a  knife-hook  with  blunted  point.  The  operation  is  not  with- 
out danger  to  the  lens;  besides,  the  adhesions  often  refused  to  yield, 
or  yielded  only  to  recur.  Moreover,  iridectomy,  it  has  been  demon- 
strated, is  a  better  remedy  for  the  irititis,  etc.,  that  sometimes  result 
from  pronounced  synechia  posterior.  A  few  slight,  isolated  attach- 
ments arc  usually  harmless.  For  these  reasons  the  operation  has 
fallen  into  disuse. 

Anterior  Synechiotomy, 

Anterior  Synechia. — Here  the  involvement  of  the  iris  is  not  so 
much  an  adhesion  to  the  cornea  as  it  is  an  incarceration,  the  extent 

1  Oph.  Hosp.  Rep.,  1857-1860. 

2  A.  f.  O.,  i86o-i86i. 


444  OPERATIONS  UPON  THE  GLOBE 

of  which  varies  greatly — from  a  few  fibres  caught  up  by  a  linea- 
or  punctate  scar,  to  the  inclusion  of  the  greater  portion  of  the  memr 
brane  in  a  leucoma  {leucoma  adherens).  The  surgical  treatment 
applies  more  to  the  second  category  just  mentioned,  as,  aside  from 
a  few  special  measures  and  instruments  relative  to  the  synechia 
itself,  most  of  the  operations  are  but  phases  of  those  already  described 
in  connection  with  the  iris.  When  the  synechia  involves  only  the 
pupillary  border,  the  freeing  of  the  iris  from  the  cornea  is  called 
sphincerolysis;  when  a  more  extensive  area,  iridolysis.  Here 
follow  a  few  of  the  methods  of  dealing  with  small  synechias. 

Von  Arlt,^  in  cases  of  small,  anterior  synechia,  advised  passing 
a  lance-keratome  into  the  anterior  chamber,  advancing  the  point 
to  the  adhesion  and  trying  to  cut  it  by  a  rocking  motion  of  the  blade 
from  side  to  side.  Bowman  first  made  a  small  incision  through  the 
cornea,  then  introduced  a  probe-pointed  lacrimal  knife  to  divide 
the  synechia.  Meyer^  essayed  to  sever  the  attachment  with  a  small, 
blunt-pointed  sickle,  passed  into  the  chamber  through  an  incision, 
and  advised  cutting  from  the  periphery  toward  the  pupil.  Of 
course,  it  was  necessary  that  a  space  existed  in  the  meridian  of  the 
synechia  between  cornea  and  iris.  Lang^  used  two  knife-needles, 
one  blunted  at  the  point.  With  the  sharp  one  he  punctured  the 
cornea  obliquely  near  the  site  of  the  adhesion,  then  substituted  the 
blunt  one,  with  which,  in  the  withdrawing,  he  freed  the  iris. 

Operation  for  Synechia  Anterior. — Straub,  Amsterdam  (Tyd- 
schr.  V.  Gen.,  August  22,  1908)  speaks  in  the  Medical  Society  in 
Amsterdam,  November  27,  1907,  about  the  danger  early  or  later  of 
anter.  synechia  leading  to  higher  tension.  Perhaps  that  the  process, 
which  produced  it,  changed  more  in  the  angle  of  the  anterior  cham- 
ber, as  we  notice  in  the  living  eye;  or  the  displacement  of  the  iris 
changes  the  chamber  lymph  and  a  stronger  lymph  current  than  in 
the  normal  eye  results.  If  it  should  be  possible  to  free  the  iris  from 
the  cornea,  this  would  be  preferable  over  an  iridectomy — mostly 
opposite  to  the  synechia.  Schulck's  method  promotes  the  origin  of 
synechia  anterior.  This  can  be  prevented  by  making  the  in-and-out- 
opening  in  the  limbus.  It  can  be  used  for  a  broad  synechia,  the  so- 
called  leucoma  adherens,  where  the  place  and  extent  of  the  growing 
together  cannot  be  judged  well.  A  von  Graefe  knife  is  only  fit  to  cut 
in  a  direction  about  horizontal.     P'or  a  more  vertical  incision  this 

1  Operationslehre,  S.  341. 

2  Handb.  der  Augenb.,  Berlin,  1883,  S.  108. 
'  Oph.  Hosp.  Rep.,  vol.  xii,  1889,  p.  356. 


SYNECIIIOTOMY  445 

knife  must  be  replaced  by  one  with  a  shorter  blade,  which  makes  an 
angle  of  about  60°  with  the  handle.  Straul)  had  such  knives  made  by 
Moria  in  Paris.  One  needs  two  knives,  each  being  the  other's  re- 
flected image.  He  has  also  two  similar  knives  with  blunt  point  to 
cut  away  remnants.  This  principle  is  from  Lang.  Straub  takes  hold 
of  the  conjunctiva  opposite  to  the  place  where  he  wants  to  make  the 
wound;  he  thrusts  Taylor's  knife  through  the  limbus  opposite  the 
middle  of  the  synechia.  The  point  of  the  knife  is  thrust  near  the 
cornea  through  the  tissue,  which  connects  iris  and  cornea,  so  that  a 
button  hole  is  made  in  the  middle  of  the  synechia.  It  is  sometimes 
possible  by  turning  the  knife  toward  right  and  left  to  cut  off  the  side 
parts  of  the  synechia,  but  great  care  is  necessary  with  a  shallow 
anterior  chamber.  He  therefore  puts  his  blunt  knives  through  the 
puncture  opening,  probes  until  the  instrument  passes  into  the  button- 
hole, pushes  it  then  more  forward  and  cuts  off  the  rest  of  the  synechia, 
the  right  bridge  with  the  knife  curved  toward  the  right,  the  left 
bridge  with  the  left  curved  knife.  Is  the  scar  so  oblique  that  its 
middle  cannot  be  reached  easily,  then  one  has  to  incise  opposite 
the  end  of  the  scar,  which  is  the  nearest  to  the  corneal  margin. 
Then  usually  only  one  knife  is  enough.  Artificial  illumination  is 
necessary.  Straub  considers  that  these  improvements  have  made 
the  operation  for  anterior  synechia  so  easy  and  safe,  that  now  to  a 
patient  recovered  with  anterior  synechia  can  be  proposed  the  exci- 
sion of  this  contact,  just  as  one  recommends  to  a  patient  iridectomy 
after  iritis,  when  he  has  recovered  with  an  extensive  posterior  syn- 
echia. Sometimes  a  bridge  is  left,  but  as  the  iris  remains  in  its  plane 
this  has  no  importance.  As  the  anterior  chamber  fills  quickly  the 
wounds  remain  separated. 

Author's  Methods. — Since  it  is  desirable  that  the  anterior 
chamber  be  not  emptied  during  the  manipulations  of  the  knife, 
every  precaution  is  taken  to  prevent  the  patient  from  squeezing 
the  globe  by  contraction  of  the  orbicularis.  To  this  end  the  eye 
is  thoroughly  anesthetized  by  cocain,  and  the  lids  are  held  apart 
by  retractors  in  the  hands  of  a  competent  aid.  If  pressure 
upon  the  globe  can  be  avoided  the  chamber  may  be  kept  intact, 
using  the  lance-knife,  till  the  final  withdrawal  of  the  knife,  and, 
using  the  Graefe  model,  it  need  not  be  emptied  at  all.  Anterior 
synechias  of  considerable  extent  can  be  severed  most  satisfactorily 
with  either  of  these  instruments.  The  best  form  of  lance-keratome 
is  one  much  after  the  model  of  Agnew's  that  is,  long  and  narrow  of 


446  OPERATIONS  UPON  THE  GLOBE 

blade.  The  globe  is  fixed  by  being  seized  with  the  broad-jawed 
forceps  near  that  part  of  the  limbus  directly  opposite  the  point  it  is 
proposed  to  puncture  with  the  lance.  This  puncture  is  started  just 
back  of  the  union  of  conjunctiva  and  cornea.  The  blade  is  pushed 
across  the  chamber  until  its  point  is  well  beyond,  and  with  its  edge 
in  contact  with,  the  synechia.  Now,  twisting  the  handle  so  as  to 
firmly  engage  the  adherent  portion  of  the  iris,  the  latter  is  divided 
in  the  withdrawal  by  a  sort  of  slicing  movement  of  the  blade.  The 
greatest  objection  to  the  lance  is  the  inevitable  emptying  of  the 
chamber  which  ensues  at  the  finish  of  the  operation.  This  may,  and 
sometimes  does,  result  in  the  reunion  of  the  iris  and  cornea.  Hence, 
more  recently  the  lance  has  been  replaced  by  the  discissions  knife 
described  on  page  585.  By  reason  of  the  fact  that,  with  this  instru- 
ment, the  evacuation  of  the  aqueous  can  be  forestalled,  the  freeing 
of  the  adhesion  is  more  likely  to  be  permanent.  As  with  the  lance, 
the  puncture  is  begun  well  back  of  the  apparent  limbus,  or  in  con- 
junctival tissue.  The  objects  here  are  to  insure  rapid  healing,  there- 
fore, safety  from  infection,  and  to  obtain  a  long  wound-canal,  which 
is  a  strong  safeguard  against  escape  of  the  aqueous.  This  minia- 
ture Graefe  knife  offers  another  advantage  in  that  only  the  terminal 
6  mm.  of  its  blade  have  cutting  qualities,  thus  permitting  the  opera- 
tor to  impart  a  slight  sawing  motion  to  it  without  risk  of  enlarg- 
ing the  wound  of  entrance  and  spilling  aqueous. 

When  the  anterior  synechia  is  complicated  by  traumatic,  secondary 
cataract,  as  is  frequently  the  case,  it  is  unwise  to  attempt  too  much  at 
a  single  sitting.  Having  dealt  with  the  anterior  synechia  after  the 
manner  last  described,  rather  than  turn  one's  attention,  for  example, 
immediately  to  an  opening  up  of  the  obstructed  pupil,  it  were  best 
to  apply  the  bandage  at  once.  Further  twisting  and  revolving  of  the 
knife  would  almost  certainly  result  in  emptying  the  chamber  and, 
probably,  also  in  the  breaking  through  into  the  vitreous.  The 
matter  of  ridding  the  pupil  of  the  secondary  cataract,  or  that 
of  dividing  any  irido-capsular  adhesions,  one  can,  with  far  greater 
prudence,  leave  for  a  subsequent  intervention. 

For  the  more  extensive  adhesions  between  cornea  and  iris,  a  number 
of  simple  and  combined  measures  have  been  employed— a  few^ 
of  them  effective,  many  ingenious.  Naturally,  the  phase  of  irido- 
corneal adhesion  that  has  specially  concerned  the  surgeon  is  that 
where  exists  blindness  from  incarceration  of  the  entire  sphincter. 
I  have  seen  Dr.  Agnew  obtain  the  o])ject  sought    in  sucli  a  case 


IRIDKCroMY  447 

by  inserting  his  angular  lance  as  if  for  an  ordinary  optic  irideclomv, 
then  piercing  the  iris  just  short  of  where  it  entered  the  cicatrix,  and 
pushing  the  point  into  the  ])Osterior  chamber,  thus  freeing  the  iris 
sufficiently  to  admit  of  a  small  iridectomy,  which  he  at  once  j^roccedetj 
to  make.  Again,  where  the  limited  space  between  cornea  and  iris 
would  not  i^ermit  tlie  handling  of  the  lance-knife,  the  same  surgeon 
would  accomplish  the  end  thus :  A  very  narrow  Graefe  knife  is  i)assed 
into  the  anterior  chamber  close  down  to  the  limbus,  the  iris  is 
partly  severed  from  the  scar  with  the  point  of  the  knife,  counter- 
puncture  made,  the  section  completed,  the  loosened  segment  of  iris 
pulled  out  with  forceps  and  cut  off. 

For  elaborations  of  this  branch  of  ocular  surgery  the  reader  is 
referred  to  the  second  volume  of  Czermak-Elschnig's  '^Augcn- 
arztlichen  Operationen,"  p.  189,  where  are  given  descriptions  of 
the  very  original  methods  of  the  Hungarian  ophthalmic  surgeon 
Schulek. 

IRIDECTOMY. 

This  is  a  surgical  measure  whereby  a  portion  of  the  iris  is  excised. 
The  first  iridectomies  on  record  were  probably  those  made  by 
Daviel^  to  facilitate  the  removal  of  cataract.  It  was  Reichenbach,'- 
however,  who  first  proposed  partial  excision  of  the  iris  as  a  separate 
and  independent  procedure;  and  for  making  the  coloboma  he  de- 
signed a  sort  of  punch  or  trephine.  Janin  about  1772,  cut  oil  a 
prolapse  of  the  iris  that  had  occurred  in  an  attempt  to  make  an 
iridotomy,  and  remarked  how  little  was  the  tendency  of  the  resulting 
pupil  to  close,  as  compared  with  that  produced  by  the  older  opera- 
tion of  iridotomy.  The  elder  deWenzeP  made  numerous  iridec- 
tomies in  conjunction  with  his  cataract  cases,  either  at  the  time  of 
the  extraction  or  afterward,  to  create  an  artificial  pupil  in  atresia  of 
the  iritic  membrane.  These  operations  were  mostly  of  the  sub- 
corneal variety,  i.e.,  the  sections  of  the  iris  were  made  within  the 
anterior  chamber,  in  contradistinction  to  the  pre-corneal  kind,  as 
usually  practised,  wherein  the  portion  to  be  removed  is  withdrawn 
with  a  traction  instrument  before  being  severed.  The  great 
Viennese  ophthalmic  surgeon,  George  Joseph  Beer,  was  the  ])ioncer 

1  De  Wecker,  "Reminiscences  historiques,  etc.,"  Arcli.  d'opht.,  t.  xiii, 
18Q3. 

-Dissertation,  Tubingen,  1767. 

3  Traitc  de  la  Cataract,  Neuremherg,  1788,  p.  188. 


448  OPERATIONS  UPON  THE  GLOBE 

of  the  latter  mode,  which  he  first  conceived  in  1806.  Not  only  this, 
but  he  greatly  enlarged  the  sphere  of  the  measure  by  applying  it  to 
cases  other  than  those  wherein  the  lens  was  opaque  or  was  absent, 
as  in  staphyloma  and  opacities  of  the  cornea,  for  artificial  pupil.  He 
also  gave  a  correct  method  of  technic  and  fitting  instruments  for  the 
making  of  the  operation.  His  broad,  triangular  cataract  knife  was 
used  for  the  corneal  incision,  which  he  made  as  close  as  possible 
to  the  sclera.  If  there  was  no  posterior  synechia,  the  sphincter  was 
caught  by  a  small  sharp  hook,  pulled  out,  and  the  section  made 
with  small  Daviel  scissors.  If  adhesions  w.th  the  anterior  capsule  or 
cornea  existed,  the  withdrawal  was  by  means  of  tiny  toothed  forceps. 

The  operation  underwent  slight  modifications  at  the  hands  of 
Beer's  immediate  disciples,  as  Walther,  Langenbeck,  Rosas,  Chelius, 
Flarer,  and  the  two  Jaegers,  Karl  and  Friederich;  in  England,  at 
those  of  Gibson  and  Tyrrell,  and,  in  France,  at  those  of  Sichel  and 
Desmarres.^  The  last  mentioned  added  iridorrhexis,  or  tearing  of 
the  iris  from  its  periphery,  to  increase  the  breadth  of  the  coloboma. 
But  it  is  to  the  most  distinguished  pupil  of  both  Beer  and  Desmarres, 
viz.,  the  immortal  Albrecht  von  Graefe,  that  the  world  is  indebted 
for  the  inestimable  value  of  iridectomy  as  a  curative  agent,  espe- 
cially in  recurrent  iritis  and  irido-cyclitis,^  and  in  glaucoma.^  Did 
the  fame  of  this  versatile  and  subtle  genius  in  ophthalmology  rest 
only  upon  this  last-named  discovery,  it  were  enough,  and  more, 
for  all  time,  and  the  beneficient  results  thereof  were  an  all-sufficient 
monument. 

As  may  be  inferred  from  perusal  of  the  foregoing  historic  sketch, 
where  the  chief  offices  of  iridectomy  are  touched  upon,  the  forms 
and  uses  of  the  operation  are  varied.  The  principal  kinds  and  their 
indications  may  be  thus  tabulated: 

KINDS  OF  IRIDECTOMY  AND  THEIR  INDICATIONS. 

1.  Preparatory  iridectomy,  or  that  which  is  employed  in  con- 
junction with  the  extraction  of  cataract, 

2.  Optic  iridectomy,  or  the  making  of  an  artificial  pupil  for 
visual  purposes. 

3.  Therapeutic  iridectomy,  that  which  is  undertaken  for  the  cure 
or  for  the  prevention  of  morbid  processes  in  the  eye. 

1  Traits  des  maladies  des  yeux,  1855,  T.  ii,  p.  542. 

2  Arch.  f.  Ophth.,  ii,  1856,  S.  202. 

3  Arch.  f.  ()])litli..  iii,  2,  S.  456,  1857. 


OPTIC    IRIDECTOMY  449 

1.  Preparatory  iridectomy  is,  as  has  been  stated,  the  oldest 
form  of  the  operation.  It  is,  moreover,  the  purest  form  of  iridec- 
tomy. It  is  made  either  immediately  preceding  the  extraction, 
thus  constituting  the  combined  operation,  or  some  weeks  or  months 
previously,  when  it  is  called  preliminary  iridectomy.  Combined 
iridectomy  was  the  original  kind,  having  been  that  of  Daviel  and  of 
ophthalmic  surgeons  in  general,  for  more  than  loo  years  following 
the  introduction  of  the  operation  of  extraction.  It  was  first  in- 
tended merely  as  an  aid  to  the  delivery  of  the  cataract,  as  in  cases 
of  rigidity  of  the  pupil,  luxation  of  the  lens,  etc.  Later,  the  pro- 
cedure was  resorted  to  in  order  to  prevent  iris  entanglements 
(Schifferli,  1776),  and,  still  later,  with  the  view  of  warding  off  iritis 
and  suppuration  of  the  wound  (Graefe,  1850).  The  late  Prof. 
Mooren,  of  Berlin,  in  1862,  was  the  author  of  preliminary  iridectomy, 
which  he  practised  with  the  idea  of  lessening  the  dangers  of  sup- 
puration after  operations  for  cataract.  'The  chief  objects  of  pre- 
paratory iridectomy,  as  practised  to-day,  are  to  facilitate  extraction — 
particularity  as  regards  removal  of  cortical  remains  and  to  forestall 
iris  complications  as  sequela;  of  extraction.  Some  eye  surgeons 
make  preparatory  iridectomy  only  as  occasion  demands,  as  in  com- 
plicated cataract,  the  others  never  omit  it.  In  this  connection  the 
operation  is  treated  of  under  "Extraction  of  Cataract." 

2.  Optic  iridectomy,  also  called  iridesis  and  coremorpho- 
sis,  as  we  have  just  seen,  is  next,  in  point  of  age,  to  the  pre- 
paratory variety.  It  is  indicated  in  atresia,  iridis,  or  where  the 
normal  pupil  is  obscured  by  opacities  of  the  cornea,  as  partial 
leucoma;  or  of  the  lens,  as  large  pyramidal  and  zonular  cataract; 
in  occlusion  of  the  pupil,  in  subluxation  of  the  crystalline  with 
great  reduction  of  visual  acuity — in  short,  w^henever  it  is  possible 
by  the  excision  of  a  portion  of  the  iris  to  restore  or  to  greatly 
improve  the  sight.  The  resulting  coloboma  should  be  small,  to 
insure  a  clean  image,  and,  when  practicable,  should  not  extend 
to  the  periphery,  because  of  the  imperfect  refraction  and  senile 
changes  that  characterize  this  region.  As  to  the  position  of  the 
artificial  pupil,  when  one  has  the  option,  it  is  customary  to  place  it 
downward  and  inward.  Really,  provided  it  does  not  lie  beneath 
the  lid  and  is  not  too  eccentric,  the  situation  of  the  opening  is, 
dioptrically  considered,  of  little  or  no  consequence.  Indeed,  as 
regards  the  lens,  this  is  a  matter  to  be  decided  solely  by  the  site  of  the 
opacity,  and,  as  concerns  the  cornea,  by  data  obtained  from  careful 

29 


450  OPERATIONS  UPON  THE  GLOBE 

Study  of  the  available  parts  of  that  membrane.  To  this  end,  it  is 
of  the  utmost  importance  that  not  only  the  degree  of  transparency 
of  the  different  areas  be  ascertained,  by  means  of  strong  focal 
illumination  and  magnifying  glasses,  but  that  one  takes  into  con- 
sideration their  curvature,  as  revealed  by  such  implements  as 
Placido's  disks,  the  ophthalmometer  and  the  ophthalmoscope. 
Especial  care  should  be  given  the  opthalmoscopic  examination, 
since  transmitted  light  and  a  strong  plus  lens  will  reveal  corneal 
areas  practically  opaque  on  account  of  diffraction,  which  could  not 
be  seen  by  other  methods  of  examination.  That  portion  of  the 
cornea  which  is  freest  from  opacities  and  irregular  astigmatism 
should  be  chosen  as  the  sight  of  the  coloboma.  These  investigations 
are  to  be  made,  whenever  possible,  with  full  mydriasis,  before 
subjecting  the  patient  to  the  operation.  In  zonular  cataract  and  in 
subluxation  of  the  lens,  one  must  be  fairly  sure  that  increased  vision 
will  ensue,  for  the  best  made  optic  iridectomy  is  apt  to  prove  disap- 
pointing in  these  defects.  A  piece  of  card-board  or  other  dia- 
phragm, stenopaically  perforate,  used  in  such  a  way  as  to  cause  a 
narrow  pencil  of  light  to  pass  through  the  different  parts  of  the  dilated 
pupil  will,  occasionally,  solve  the  problem  in  question.  In  many 
instances,  however,  the  area  of  clear  cornea  is  so  limited  that  the 
location  of  the  coloboma  becomes,  not  a  matter  of  choice,  but  of 
necessity.  If  one  be  obliged,  by  the  exigencies  present,  to  make 
the  iridectomy  in  an  unfavorable  position,  other  artificial  means 
may  often  be  evoked  for  heightening  the  visual  results.  If,  for 
example,  it  be  extremely  peripheral,  cylindrical  lenses  can,  in  many 
cases,  be  fitted  with  benefit.  If  diffusion  is  caused  by  the  light  that 
passes  through  thin  opacities  in  the  immediate  vicinity  of  the  clear 
spot  selected,  the  image  can  be  sharpened  by  tattooage  (see 
page  413).  The  same  may  be  done  to  advantage  in  the  event  of 
too  large  a  coloboma,  by  way  of  "stopping  down,"  as  it  were. 

Now  and  then  it  happens  that  one  is  confronted  with  a  patient 
whose  only  hope  of  obtaining  a  modicum  of  sight  is  through  the 
making  of  an  opening  in  the  iris  beneath  a  tiny  area  of  cornea 
situated  at  the  extreme  i)eriphery.  If  the  incision  encroaches  upon 
this  area,  the  ensuing  scar  will  cloud  the  new  pupil.  One  has,  then^, 
the  choice  between  entering  the  angle  of  the  iris  through  a  long 
wound-canal  by  way  of  the  adjacent  sclera,  or  of  making  a  com- 
bination of  irido-dialysis  and  iridectomy,  as  resorted  to  by  Panas. 
This  surgeon  would  make  the  corneal  incision  on  the  side  o]ij)Osite 


OPTIC    IRIDECTOMY  45  T 

reach  across  the  ]iui)il  willi  the  lOrcc])s,  seize  the  iris  iK-nealh  UK- 
spot  of  clear  cornea,  lear  it  from  the  peripliery,  willulraw,  and 
excise.     Both  methods  are  dilficult. 

A  drawback  to  the  artificial  pu])il  is  its  I'lxidity,  nolwithstandinj^ 
the  varying  intensities  of  illumination.  It  was  to  obviate  this  that 
Adams,  in  1812,  and  Himly,  in  i843,  proposed  displacing  the 
natural  pupil  in  the  desired  direction  by  drawing  the  iris  into  the 
corneal  wound  and  there  leaving  it  to  be  incarcerated — iridendeisis. 
It  was  to  the  same  end  that  Oitchetl,  in  1857,  devised  his  operation 
of  ligature  of  the  iris — iridcsis,  or  iridodcsis.  This  consisted  in 
making  a  small  incision  with  a  broad  needle  or  lance-knife  as  near 
as  possible  to  the  base  of  the  cornea,  withdrawing  with  cannula- 
forceps  the  nearest  portion  of  the  sphincter,  throwing  a  delicate 
silk  ligature  around  the  part  brought  out,  leaving  it  thus  for  two  days 
in  order  that  the  iris  might  become  firmly  adherent  in  the  wound, 
then  cutting  off  the  extrusion  or  allowing  it  to  slough.  These 
measures  proved  excellent  in  so  far  as  their  optic  effects  were  con- 
cerned, seeing  that  they  gaveanarrow,  movable  pupil,  but  disastrous 
as  regarded  their  physical  consequences — among  the  last  having 
been  iridocyclitis,  glaucoma,  and  sympathetic  ophthalmia.  Hence, 
their  respective  vogues  were  short-lived.  As  a  safe  substitute  for 
them,  in  the  year  187 1,  Pope,^  brought  forward  his  method  of 
making  an  optic  iridectomy  without  dividing  the  sphincter  of  the 
pupil.  With  a  very  narrow  keratome  he  entered  the  extreme 
periphery  of  the  anterior  chamber  by  way  of  an  almost  scleral 
wound,  allowed  the  aqueous  to  drain  slowly  to  avoid  a  prolapse, 
seized  with  line,  slightly  curved  forceps,  the  iris  in  the  center  of  the 
exact  spot  to  be  excised,  and  withdraw,  taking  care  that  the  pupil- 
lary border  came  not  into  the  incision.  Then,  with  small  curved 
scissors,  just  as  much  was  cut  off  as  was  held  by  the  forceps.  If 
a  round  coloboma  was  wanted,  the  scissors  blades  were  held  at  right 
angle  to  the  direction  of  the  corneal  wound;  if  an  oval  section  was 
preferred,  the  blades  were  held  parallel  with  the  wound.  The 
remaining  portion  of  the  pulled-out  iris  was  gently  replaced. 

Such  an  artificial  pupil  has  certain  advantages — among  them 
being  its  small  size,  its  slight  disfigurement,  and  the  little  tendency 
it  has  to  widen  or  to  be  drawn  toward  the  root  of  the  iris.  Singular, 
that  the  procedure  has  so  few  advocates.  One  reason  is,  doubtless, 
the   popular   belief   that   double   vision — polyopia — and    a   double 

1  Arch.  f.  A.  u.  O.,  ii,  i,  S.  192-197. 


452  OPERATIONS  UPON  THE  GLOBE 

pupil — polycorla — go  together.  Such,  however,  is  not  hkely  to  be 
the  case  even  when  the  normal  pupil  is  unobstructed,  much  less 
so  when  it  is  obscured,  as  is  precisely  the  condition  for  which  an 
optic  iridectomy  is  made.  Another  reason  for  the  relative  rarity 
of  the  measure  is  the  difficulties  that  attend  its  proper  execution. 
These,  however,  should  not  stand  in  the  way.  If,  for  instance, 
the  sphincter  should  be  inadvertently  embraced  in  the  section, 
the  result  amounts  only  to  an  ordinary  iridectomy.  If  merely 
a  thread-like  bridge  at  the  very  border  of  the  pupil  be  left  behind, 
it  amounts  to  the  same,  since  it  will  most  probably  atrophy  and 
disappear.  The  really  substantial  difficulty  lies  in  the  making 
of  the  ideal,  perfectly  peripheral,  primary  incision,  which  will  be 
described  under  the  "Technic  of  Iridectomy."  I  have  several 
times  of  late,  had  recourse  to  this  form  of  iridectomy  when  a  highly 
eccentric  pupil  was  demanded,  and  commend  it  most  heartily. 
The  common  practice  of  introducing  a  blunt  hook  or  other  instru- 
ment to  get  rid  of  a  pupillary  bridge  accidentally  left  in  the  operation 
of  optic  iridectomy— or  any,  save  in  preparatory  iridectomy— is  to 
be  deprecated. 

Sphincterectomy. — The  most  eligible  method  of  optic  irid- 
ectomy, w^here  existing  conditions  permit  the  more  centrally  placed 
coloboma,  as  in  central  leucoma  of  the  cornea,  is  what  is  called 
sphincterectomy,  and  is  that  with  which  Critchett  replaced  his  un- 
fortunate iridesis.  Briefly  described,  the  manner  of  performing 
it  is  as  follows:  Incision  3  or  4  mm.  in  extent  with  a  narrow 
keratome,  beginning  in  the  opaque  zone  at  the  sclero-corneal  junc- 
tion. If  deftly  made,  the  knife  may  be  quickly  withdrawn  without 
loss  of  the  aqueous  and  without  causing  the  iris  to  follow  the 
blade  into  the  wound.  These  two  things  are  desirable  for  two 
reasons,  viz.,  a  certain  depth  of  the  anterior  chamber  favors  the 
manipulation  of  the  iris  forceps,  and  having  the  iris  spread  out 
in  its  normal  relations  is  conductive  to  the  accurate  dosage  of 
the  excision.  With  fine,  moderately  curved,  back-toothed  forceps 
(or  median-toothed),  the  iris  is  seized  near  the  pupil,  drawn  out 
sufficiently  to  expose  the  pupillary  border,  and  a  small  triangle  of 
the  uveal  lining,  and,  with  a  single  snip  of  the  curved  iris  scissors, 
or  the  De  Wecker  forceps  scissors,  the  blades  crosswise  to  the 
primary  incision,  a  small  piece,  comprising  a  little  more  than  the 
sphincter  itself,  is  excised.     The  unsevered  portion  is  gently  replaced 


THERAPEUTIC    IRIDECTOMY  453 

with  the  spatula,  the  eye  washed  with  ;i  mild  anlisei)tic  sokition, 
and  the  dressings  apphed. 

3.  Therapeutic  Iridectomy.— This  variety  of  irideclomy  is 
cither  prophylactic  or  curative  or  both.  In  the  iirst  capacity  its 
chief  indication  is  in 

a.  Recurrent  Iritis  or  Irido-cyclitis.— In  the  second  caj^acity 
therapeutic  iridectomy  llnds  its  main  oflicc  in 

b.  Glaucoma. — It  is  both  remedy  and  prevenli\e  in  certain 
instances  of 

c.  Foreign  bodies  in,  tumors,  parasites,  and  prolapse  of,  the  iris, 
a.  Iridectomy   has   proven   of  great   value   in   cases   of  partial 

posterior  synechia,  characterized  by  relapses  of  iritis,  provided 
the  operation  is  made  in  an  interval  when  the  eye  is  absolutely  quiet. 
This  is  especially  true  of  cases  where  exists  exclusion  of  the  pupil 
more  or  less  complete.  For  these,  the  excised  portion  of  iris  need 
be  only  of  small  dimensions,  and  no  necessarily  peripheral,  except 
there  be  a  tendency  to  glaucoma.  In  complete  exclusion  of  the 
pupil,  unless  there  be  occlusion  besides,  the  coloboma  is  made  to 
reestablish  communication  between  the  anterior  and  posterior 
chambers,  and  is  best  made  upward,  so  as  to  lie  beneath  the  upper 
lid;  if  the  exclusion  is  incomplete,  however,  the  position  of  the 
coloboma  will  be  determined  by  that  of  the  free  section  of  the 
pupillary  border.  This  is  ascertained  by  noting  the  effect  of  a 
mydriatic  upon  the  contour  of  the  pupil.  Associated  with  these 
conditions  the  iris  is  apt  to  present  the  symptomatic  appearance 
known  as  "crater-shape,"  and  iris  bombe,  due  to  a  bulging  forward 
of  the  free  middle  zone  by  pressure  of  the  aqueous  in  the  posterior 
chamber.  It  must  not  be  supposed  that  this  peculiar  configuration 
of  the  surface  of  the  iris  always  indicates  that  the  middle  zone  is 
not  adherent  to  the  lens  capsule.  The  apparent  bellying  forward 
may  be  but  the  swelling  caused  by  the  infiltration  or  the  thickening 
to  which  this  region  of  the  iris  is  more  prone,  and  there  may  be 
total  posterior  synechia.  Under  such  conditions,  iridectomy  under- 
taken for  either  therapeutic  or  optic  purposes,  is  almost  sure  to  be 
a  disappointment;  for,  aside  from  the  difficulty  of  making  an  ade- 
quate incision,  it  is  usually  impossible  to  excise  any  but  the  stroma 
of  the  iris,  leaving  the  uvea  still  adherent  to  the  capsule.  True, 
most  gratifying  results  can,  exceptionally,  be  obtained  even  where 
the  plight  is  most  unpromising,  as  note  the  case  of  Mrs.  K.,  cited 
under    "Specially    Complicated    Extractions."     In   these   extreme 


454  OPERATIONS  UPON  THE  GLOBE 

cases,  however,  where  there  is  total  posterior  synechia,  especially 
where  exists,  in  addition,  occlusion  of  the  pupil,  obliteration  of 
the  anterior  chamber,  and,  above  all,  glaucomatous  tension,  iridec- 
tomy and  extraction  combined,  after  the  manner  of  deWenzel 
(see  page  562),  is  oftenest  the  more  fitting  measure.  If,  on  the 
other  hand,  the  intraocular  tension  is  markedly  low,  its  association 
with  the  other  features  just  enumerated  constitutes  a  positive 
contraindication  as  regards  iridectomy  and  extraction.  Neither 
could  a  few  isolated  points  of  adhesion  between  iris  and  lens  be 
construed  as  a  cause  for  iridectomy  unless,  perchance,  all  other 
forms  of  treatment  have  failed  to  stop  the  repeated  attacks  of  iritis. 

b.  Iridectomy  for  Glaucoma. — It  is  herein  that  the  operation 
performs  its  highest  function.  This  is  particularly  true  of  it  in  con- 
nection with  acute  idiopathic  glaucoma,  in  which  relation  it  has  been 
termed  antiphlogistic  iridectomy.  Whatever  the  variety  or  the 
grade  of  the  glaucoma— whether  acute  (fulminant),  subacute 
(intermittent),  chronic  (simple),  secondary  (symptomatic),  absolute 
(degenerative),  or  congenital  (hydrophthalmus),  the  same  surgical 
principles  are  applicable,  though  the  technic  and  the  instruments  by 
which  the  several  steps  are  accomplished  vary  with  the  demands  of 
the  case  and  are  treated  of  in  detail  later. 

Iridectomy,  as  regards  its  indications  in  glaucoma,  has  many 
limitations.  In  simple  or  chronic  glaucoma  it  is  admissible  only 
when  there  is  unmistakable  overtension,  either  constant  or  inter- 
mittent or  as  a  last  resort.  In  absolute  glaucoma  it  may,  perhaps, 
be  tried  when  there  is  also  glaucoma  of  the  other  eye.  In  mono- 
lateral  absolute  glaucoma,  except  the  progress  of  the  affection  is 
sufficiently  well  known  to  exclude  the  possibility  of  an  intraocular 
tumor,  such  as  melanosarcoma,  the  eye  must  be  enucleated  at  once. 
In  acute  hemorrhagic  glaucoma  it  is  allowable.  In  acute  idiopathic 
and  acute  secondary  glaucoma  following  operations  and  injuries, 
the  indications  are  positive,  imperative,  and  immediate.  The  steps 
themselves  are  notably  specialized,  and  are,  in  most  respects,  the 
direct  antithesis  of  those  in  oi)tic  iridectomy,  that  is  to  say,  the  in- 
cision must  be  as  nearly  scleral  as  practicable;  its  extent  must 
exceed  that  which  is  rc(|uire(l  merely  for  getting  at  the  iris,  being 
usually  equal  to  about  onc-fiflh  thai  of  ihe  corneal  limbus;  the 
coloboma  must  be  broad  and  reach  10  the  very  root  of  the  iris;  the 
location  of  the  coloboma  is  a  fixed  one,  i.e.,  in  the  ui)per  segment 
of  the  iris. 


THE    I'll'II,    I\    IRIDKCTOMY  455 

c.  Therapeutic  irideclomy  of  the  third  class  is,  as  stated,  both 
prophylactic  and  curative;  moreover,  in  order  to  fulfill  the  first  three 
indications  mentioned  under  this  heading,  viz.,  foreign  bodies, 
tumors,  and  parasites  in  the  iris,  the  methods  to  be  employed  par- 
take of  those  appropriate  to  both  o])tic  iridectomy  and  that  for 
glaucoma.  To  remove  a  clean  foreign  body  which  has  but  recently 
become  entangled  in  the  iris,  for  example,  the  length  of  the  primary 
incision  shall  not  be  greater  than  is  ample  for  proper  manipulation 
of  the  forceps,  nor  placed  back  of  the  limbus,  except  when  the 
situation  demands  it,  nor  the  piece  of  iris  excised  be  much  larger  or 
more  peripheral  than  is  sufficient  to  include  the  offending  sub- 
stance. Given,  a  sarcoma  of  the  iris,  however,  while  the  same 
holds  good  as  regards  the  incision,  the  segment  excised  must  not 
only  be  larger,  all  around,  than  the  apparent  size  of  the  tumor,  but 
must,  in  every  instance,  extend  to  the  outer  limits  of  the  anterior 
chamber,  no  matter  how  diminutive  nor  how  centrally  placed  the 
neoplasm.  The  same  might  be  said  concerning  foreign  bodies  of  a 
poisonous  nature,  such  as  copper,  or  those  around  which  a])pear 
fungoid  growths  or  pus.  The  primary  incision  will,  on  occasion, 
need  to  be  extensive  and  sclerally  placed. 

The  fourth  indication  in  this  series — prolapse  of  the  iris — necessi- 
tates iridectomy  when  the  protruding  membrane  cannot  be  re- 
placed in  its  normal  position,  be  it  the  result  of  disease,  of  trauma, 
or  of  an  operation.  The  modes  of  dealing  with  this  condition  are 
elsewhere  described. 


GENERAL  CONSIDERATIONS  RELATIVE  TO  THE 
DIFFERENT  KINDS  OF  IRIDECTOMY. 

^Models  and  management  of  the  iridectomy  instruments  are 
treated  of  in  special  chapters  as  is  also  preparation  of  the  eye. 

Mydriatics  and  Myotics. — As  a  rule,  neither  a  mydriatic  nor  a 
myotic  is  greatly  wanted  in  fitting  the  eye  for  an  iridectomy,  though 
there  are  exceptions.  Some  surgeons  advise  against  mydriasis  in 
every  instance.  It  is  certainly  not  admissible  in  cases  characterized 
by  increased  intraocular  tension  and  pre-existing  mydriasis.  Yet 
a  dilated  pupil  is  desirable  in  certain  optic  iridectomies;  for  example, 
where  the  border  of  the  normal  pupil  is  hidden  by  0])acity  of  the 
cornea,  for  to  have  the  sphincter  in  view  aids  precision  and  lessens 
risk  as  to  the  lens  and  in  the  handling  of  the  iris  forceps.     It  also 


456  OPERATIONS  UPON  THE  GLOBE 

has  its  advantages  when  the  pupil  is  narrow,  particularly  if  rigidity 
of  the  sphincter  is  suspected,  to  promote  relaxation,  if  for  nothing 
else.  The  less  traction  required  to  withdraw  the  iris,  the  less  pain 
and  movement  on  the  patient's  part.  Any  untoward  dilation  will 
always  disappear  with  evacuation  of  the  aqueous.  To  have  an 
extremely  wide-open  pupil  while  making  the  corneal  incision 
would  be  objectionable,  for  the  following  reasons:  the  bunched  up 
iris  would  be  more  apt  to  get  in  the  way  of  the  point  of  the  keratome, 
would  be  predisposed  to  follow  the  knife  into  the  wound,  and  more 
difficult  to  properly  seize  with  the  forceps.  Fortunately,  this  does 
not  occur  except  there  be  glaucoma.  Whenever,  therefore,  it  is 
possible  in  this  disease,  to  reduce  a  considerable  or  an  ad  maximum 
dilation  by  the  use  of  a  myotic,  the  same  should  be  done.  Thus 
the  iris  becomes  better  spread  out  and  more  accessible. 

Anesthesia. — Narcosis  is  indispensable  with  children,  irre- 
sponsible and  timorous  adults,  and  with  all  eyes  that  are  hyperemic 
and  iniiamed.  There  is  no  operation  in  the  whole  domain  of 
surgery  more  exacting  upon  the  care  and  skill  of  the  operator  than 
is  that  of  iridectomy,  and  all  the  circumstances  attendant  upon 
the  measure  should  be  as  favorable  as  can  be  made.  To  have  one's 
patient  asleep  not  only  renders  him  (or  her)  incapable  of  doing  harm, 
but  gives  greater  confidence  to  the  operator.  Modern  methods  of 
general  anesthesia  and  the  substances  employed,  such  as  chlorid  of 
ethyl  and  nitrous  oxid  in  conjunction  with  ether,  have  eliminated 
danger  to  such  a  degree  as  to  make  them  applicable  to  most  any 
subject.  Hence,  if  one  has  any  misgivings  as  to  the  patient's  be- 
havior, or  as  to  the  difficulties  of  the  operation,  he  would  better  in- 
voke their  aid.  The  anesthesia  of  chlorid  of  ethyl  alone  is  sufficient 
for  the  simpler  and  more  quickly  executed  iridectomies.  It  is  im- 
portant that  the  narcosis  be  maintained  until  after  the  toilet  of  the 
wound  is  fmished,  for  much  depends  upon  the  thoroughness  of  this 
feature. 

Local  anesthesia,  too,  has  its  advantages,  for  by  its  use  the 
patient  is  not  subjected  to  the  added  risks  and  inconveniences,  as 
from  vomiting,  etc.,  consequent  upon  narcosis,  and  it  is  a  satisfaction 
to  operate  upon  an  eye  that  is  thoroughly  under  the  control  of  its 
possessor.  Aside,  however,  from  their  other  drawbacks  in  this  con- 
nection, just  alluded  to,  they  have  others.  For  instance,  as  to 
cocain,  if  one  waits  to  begin  the  operation  till  the  iris  is  anesthetized, 
there  is  likely  to  be  mydriasis,  injury  to  the  corneal  epithelium,  and 


TECHNIC    OF    IRIUECTOMY 


457 


secondary  dilatation  of  the  blood-vessels,  ergo,  hemorrhage.  These 
hindrances  might  be  done  away  with  by  the  choice  of  some  other 
local  anesthetic  than  cocain,  yet  still  would  there  remain  a  large 
proportion  of  cases  suitable  only  for  narcosis.  Adrenalin,  or  its 
like,  I  have  found  to  cause  unpleasant  after-effects,  and  by  their 
secondary  action  they  are  also  conductive  of  bleeding. 

Technic  of  Iridectomy. — The  operation  must  be  described  in 
general  terms,  leaving  specific  methods  and  modifications  to  be  dealt 


Fig.  26S. — Iridectomy  (optical  here)  through  the  inner  haLf  of  the  cornea.     Surgeon 
stands  on  opposite  side. 

with  later.  The  patient  lies  on  a  table.  For  all  upward  iridectomies 
the  operator  is  usually  stationed  at  the  head,  though  a  few  prefer,  for 
these,  to  stand  at  the  side  nearer  the  eye,  which,  of  course,  necessitates 
an  inverse  handling  of  the  instruments,  i.e.,  pulling  the  keratome  in- 
stead of  shoving  it,  (Fig.  269)  and  pushing  out  the  iris  in  lieu  of  draw- 
ing it  out.  For  inward  iridectomy  the  favorite  place  for  the  surgeon 
using  the  bent  keratome  is  on  the  side  opposite  that  of  the  eye 
concerned,  (Fig.  268)  while  in  downward  and  external  iridectomies, 
it  is  on  the  side  adjacent.  The  assistant  takes  position  facing  the 
operator.  The  blepharostat  is  used,  excepting  in  cases  where 
loss  of  vitreous  is  to  be  apprehended,  in  which  event  the  assistant 
holds  the  upper  lid  with  a  Desmarres  reactor  and  the  lower  with  his 
fingers.  The  globe  is  steadied  by  grasping  the  conjunctiva  and 
episcleral  tissue  close  up  to  the  cornea,  just  across  from  the  site  of 
the  incision,  with  strong  fixation  forceps  having  no  catch.     The  hold 


458 


OPERATIONS    UPON    THE    GLOBE 


of  the  forceps  must  be  deep  and  broad.  The  point  of  the  keratome 
is  j)laced  at,  or  slightly  back  of,  the  sclero-corneal  junction,  with  its 
bhide  almost  perpendicular  to  the  globe,  cautiously  shoved  in  till 
the  thickness  of  the  corneal  base  has  been  perforated  or  till,  by  the 
feel,  it  is  known  that  it  has  barely  entered  the  anterior  chamber. 
The  handle  of  the  knife  is  then  depressed,  to  bring  the  blade  parallel 
with  the  plane  of  the  iris,  just  above  which  membrane  it  is  pushed 
along,  taking  care  that  the  point  engages  nothing  more,  and  that 
neither  edge  encroaches  upon  either  clear  cornea  or  upon  the  ciliary 


Fig.  269. — Miinncr  of  making  keratome  incisi 


facing  the  patient. 


body  until  it  is  deemed  wise  to  stoj)  (Fig.  270).  Tliereupon,  the 
handle  is  further  depressed  to  avoid  wounding  the  advancing  lens, 
the  globe  is  held  firmly,  without  pressing  down  or  lifting  up  on  the 
forceps,  the  bhide  is  gently  withdrawn  a  little  way,  and  most  of  the 
aqueous  allowed  slowly  to  escape,  when  the  knife  is  wholly  withdrawn. 
Should  one  wish  to  extend  the  cut  in  the  withdrawal  of  the  knife,  the 
point  is  swung  around  in  the  direction  of  the  proposed  extension, 
but  holding  the  blade  pressed  close  up  to  avoid  j)remature  running 
out  of  acpieous,  tlu-  handk'  depressed,  and  the  incision  lengthened 
by  a  steady  movement  which  consists  in  shoving  the  whole  knife 
to  that  side   and  al  the  same   time  withdrawinLT.      Where   an   extra 


TECIINIC    OF    IKII)K(  TOMV 


459 


Ion,",'  incision  is  wanted,  as  in  .glaucoma,  one  makes  ihe  incision  with 
the  view  lo  such  enlargement.  To  this  end  tiie  incision  is  begun, 
say,  to  the  left  of  what  will  be  its  middle,  so  that  in  extending 
toward  tlie  ri.ght,  the  location  of  the  wovmd  will  be  where  originally 
planned. 

The  fixation  forceps  is  here  removed,  provided  the  eye  is  under 
<a  local  anesthetic  and  the  patient  tractable.  If  not,  the  instrument 
is  given  to  the  assistant.  To  do  this  is  a  delicate  matter.  The  aid 
lays  his  hand,  palm  up,  on  the  patient's  face,  slides  it  deftly  beneath 


I'lG.  270. — Manner  of  making  incision  for  iridci  loin}-. 

that  of  the  operator,  and  grasps  the  blades  hrmly  close  under  the 
surgeon's  fingers.  If  there  be  any  doubt  as  to  the  outcome  of  the 
maneuver,  the  surgeon  would  better  release  the  forcei)s  from  the 
eye,  give  them  to  the  aid,  and  let  the  latter  catch  his  own  hold. 
Having  done  so,  he  watches  his  forceps,  and  not  the  i)rogress  of  the 
operation,  save  that  he  may  know  when  to  let  go. 


460 


OPERATIONS    UPON    THE    GLOBE 


The  operator  picks  up  the  iris  forceps  in  one  hand,  the  scissors 
in  the  other,  the  one  with  jaws  tightly  closed,  the  other  with  blades 
moderately  open.  The  eye  is  turned  so  as  to  look  somewhat 
downward.  The  tip  of  the  forceps  is  placed  immediately  behind 
the  incision,  the  scissors  brought  in  close  proximity,  and  both 
instruments  held  in  the  most  stable  manner.     The  posterior  lip 


Fig.  271. — Excision  of  the  iris. 


of  the  wound  is  depressed  by  the  forceps,  the  closed  blades  are 
advanced  with  a  slight  motion  from  side  to  side  beneath  the  anterior 
lip.  They  are  made  to  hug  tlie  under  lip  until  their  extremities 
are  within  the  anterior  chamber,  when  they  are  made  rather  to 
follow  the  posterior  surface  of  the  cornea,  not  to  disturb  the  iris, 
till  the  point  is  reached  for  seizing  that  membrane.  The  blades  are 
now  allowed  to  separate  just  enough  to  get  the  necessary  hold — 
usually  about  2  mm.  The  patient,  if  conscious,  is  told  to  keep 
quiet  even  tliougli  a  slight  twinge  of  pain  ensues,  the  iris  is  firmly, 


TOILET  AFTKR  IRIDECTOMY  461 

but  not  roughly,  caught  and  withdrawn,  all  the  time  keeping  in  touch 
with  the  patient's  mood  and  acts.  As  the  points  of  the  forceps  emerge 
from  the  anterior  chamber,  the  open  scissors  blades  are  slid  astride 
them,  with  the  radii  of  the  cornea  if  a  small  excision  is  wanted, 
athwart  them  if  a  large  one.  When  the  pupillary  border,  together 
with  a  triangle  of  the  uveal  lining  of  the  iris,  appear  outside  the 
wound,  the  forceps  are  lifted  sufficiently  to  allow  the  scissors  blades 
plenty  of  room  to  close  beneath,  and,  holding  the  scissors  snug 
down  upon  the  eye,  the  cut  is  made  with  one  steady  snip  (Fig.  271). 
The  eye  is  douched  with  warm  boric  or  salt  solution,  the  fixation  for- 
ceps, if  employed,  is  removed,  and  the  lids  closed  to  wait  for  a  slight 
accumulation  of  aqueous.  Or  one  may  proceed  at  once,  after 
the  douching,  to  the 

Toilet  of  the  Wound  and  Eye. — If  it  had  been  deemed  best 
to  use  the  fixation  forceps  for  the  operation  proper,  that  instrument 
is  retained  for  the  toilet.  The  same  may  be  said  as  to  the  blepharo- 
stat or  retractor.  However,  if  the  patient  is  well  behaved  and  the 
orbicularis  lax,  both  blepharostat  and  fixation  forceps  may  be 
dispensed  with — the  operator  holding  back  the  upper  lid  and  the 
patient  being  made  to  look  downward  the  while.  If  no  portion  of 
the  iris  is  seen  caught  in  the  wound,  the  latter  is  patted  with  the 
flat  of  the  wet  spatula  to  cause  the  coloboma  to  appear  opened  out 
full  within  the  anterior  chamber;  such  spontaneous  return  of  the 
iris  to  position  having  occurred,  it  only  remains  to  free  the  incision 
from  shreds  of  clotted  blood  and  bits  of  pigment,  to  see  that  its 
lips  are  nicely  in  apposition,  again  douche  the  eye,  and  apply  the 
dressing.  Should  the  coloboma  not  appear  at  all  or  but  one  pillar 
thereof,  the  tip  of  the  spatula  is  inserted  at  the  extremities  (or 
extremity,  as  the  case  may  be)  just  far  enough  to  poke  the  entangled 
portion  from  between  the  ips — not  deep  down  into  the  anterior 
chamber  (Fig.  272).  This  having  been  done,  the  w'ound  is  patted 
with  the  wet  spatula  to  straighten  out  the  pillars  of  the  coloboma. 
If  actual  extrusion  of  a  part  of  the  iris  is  manifest,  it  can  be  put  in 
place  by  a  gentle  slicing  jnovement  with  the  edge  of  the  spatula, 
while,  at  the  same  time,  bearing  upon  the  lower  lip  of  the  wound 
(Fig.  273).  A  prolapse,  however,  that  will  not  readily  yield  to  such 
efforts  at  reduction,  would  better  be  pulled  up  with  the  iris  forceps 
and  cut  off  with  the  scissors.  Loose  ends  of  outlying  fragments  of 
iris  must  be  cut  off  at  once.  Every  precaution  must  be  taken  to 
prevent  injury  to  the  lens  by  a  sudden  turning  upward  of  the  globe 


462 


OPERATIONS    UPON    THE    GLOBE 


during  the  manipulation  of  the  si)atula.     The  hand  must  be  quick 
to  draw  back  the  instrument  if  need  be. 

After  the  simpler  forms  of  iridectomy  the  healing  is  usually  prompt 
and  safe,  so  that  the  patient  may  be  granted  the  liberty  consistent 
with  ordinary  quietude  and  limited  use  of  the  unoperated  eye. 
Binocular  occlusion  and  greater  restriction  are  reserved  for  the  more 
complicated  cases. 


l-'in.  272. — Frceiiif^  the  pillars  of  llu'  i(jl()l)oma — Pun-hoklcr  fashion. 

Modifications. — The  instruments  employed  in  iridectomy  are 
various,  and  the  methods  subject  to  numerous  changes,  in  accord- 
ance with  the  demands  of  the  case  and  the  notions  of  the  operator.. 

They  have  reference  mainly  to: 

(A)  The  making  of  the  kcratotomy. 

(B)  The  grasping  and  withdrawing  of  the  iris. 

(C)  The  size  and  shajjc  of  the  coloboma. 

(A)  Choice  of  a  Knife  for,  and  the  Manner  of  Making,  the 
Primary    Incision.      In    general,    the    bent    keratome  or  English. 


CHOICE    OF    KNIFE 


465 


lance-knife  is  the  most  suitable  instrument,  and  the  method  such  as 
has  just  been  described.  The  heahng  qualities  of  its  wound  are 
exceptional,  for  the  reasons  mentioned  in  the  cha])ter  on  Cataract 
Extraction.  The  size  of  the  blade  will  vary  with  the  extent  of  the 
incision  wanted.  It  is  best,  however,  that  the  angle  between  blade 
and  handle  be  uniform  for  all  sizes,  as  insisted  upon  by  Knai)]), 


I'iG.  273. — Slicing  movement — Left  liaiul. 

since  habitual  use  of  this  particular  bend  insures  greater  precision 
on  the  part  of  the  operator.  In  cases  of  very  deeply  set  eyes,  es- 
pecially if,  in  addition,  there  are  short  palpebral  slits,  and  shallow 
conjunctival  cul-de-sacs,  it  is  sometimes  very  difficult  to  make  the 
incision  in  the  ordinary  way.  Here  a  free  canthotomy,  as  the  first 
step  of  the  operation,  will  often  prove  a  great  help.  In  a  few  such 
instances  a  small  Graefe  knife  will  be  found  superior  to  the  lance. 
To  overcome  the  difficulties  in  question,  Bader^  gave  to  the  Graefe 
knife  a  shank  of  bayonet  shape.  Others,  notably  Scherk,  have 
devised  both  lance  and  Graefe  knives  with  shanks  of  similar  form  for 
like  emergencies. 

1  Lancet,  ii,  p.  760,  1874. 


464 


OPERATIONS    UPON    THE    GLOBE 


For  the  extra  peripheral  iridectomy  in  glaucoma,  with  very 
shallow  anterior  chamber,  it  will  be  necessary,  in  the  use  of  the  lance, 
to  begin  the  incision  1/2  to  2  mm.  back  of  the  apparent  sclero- 
corneal  junction  and  push  the  blade  straight  forward  with  just 
sufficient  backward  inclination  to  cause  the  point  to  enter  the  ex- 
treme outer  limit  of  the  anterior  chamber,  keeping  the  wound 
parallel  with  the  corneal  base — aiming,  as   it  were,  for   the  iridic 


Fig.  274. — Incision  for  iridectomy  in  glaucoma. 


angle — having  pierced  which,  the  handle  is  depressed  to  c'ear  the 
iris,  but  not  so  as  to  engage  the  posterior  surface  of  the  cornea,  and 
thus  ]nished  forward,  only  altering  the  plane  of  the  blade  in  the 
event  of  infringing  too  much  upon  either  iris  or  cornea,  always 
bearing  in  mind  that  it  is  safer  that  the  point  should  hug  cornea  than 
iris   (Fig.   274).     Sliould  llu-rc  l)e  no  visible  space  between  cornea 


KNIFE    FOR    IRIDECTOMY  465 

and  iris,  one  can  hardly  hope  to  make  an  adequate  incision  with  the 
bent  keratome  but  must  resort  to  either  the  unsatisfactory  proced- 
ure of  extending  the  cut  by  another  instrument  or  to  a  totally 
different  means  for  opening  the  anterior  chamber.  The  instru- 
ment most  often  chosen  for  such  cases  is 

The  Narrow  Cataract  Knife.— Ever  since  its  introduction  by 
von  Graefe,  th  s  instrument  has  been  used  by  ophthalmic  surgeons 
for  iridectomy  as  well  as  for  extraction,  either  habitually  or  in 
selected  cases.  It  becomes  almost  a  necessity  where  there  is  practi- 
cally obliteration  of  the  anterior  chamber.  The  blade  should  be 
exceedingly  narrow.  The  incision  cannot  be  started  as  far  back  of 
the  apparent  limbus  as  with  the  lance  knife,  for  the  reason  that  the 
plane  of  the  iris  is  the  same  as  that  of  the  cornea,  and  puncture  and 
counterpuncture  would  lie  too  close  together.  The  point  is  made 
to  enter  the  anterior  chamber  by  a  short  wound  canal,  the  handle 
then  depressed,  the  blade  insinuated  a  little  way,  not  pushing  it 
straight  across,  as  in  extraction,  but  rather  working  along  nearer  the 
periphery  of  the  iris,  even  pushing  back  the  more  bulging  portion  of 
the  membrane,  as  the  blade  is  advanced,  using  the  puncture  as  a 
fulcrum,  until  the  point  is  reached  for  making  the  counterpuncture, 
or  from  6  to  8  mm.  from  the  point  of  insertion.  Being  now  assured 
that  the  blade  lies  flat  upon  the  iris,  the  point  is  pushed  out  and  close 
down  to  the  limbus;  then  the  incision  is  completed  by  a  steady  saw- 
ing motion.  One  may  make  a  conjunctival  flap  at  the  Imish,  just 
as  in  the  operation  of  extraction. 

Adversely,  it  may  be  truthfully  urged  that  the  use  of  the  Graefe 
knife  leads  to  gaping  of  the  wound  and  inability  to  control  the  escape 
of  aqueous.  Hence,  seeing  that  the  instrument  is  resorted  to  mostly 
in  glaucomatous  eyes,  dislocation  of  the  lens,  jamming  of  that  body 
into  the  incision,  or  even  its  escape,  prolapse  of  the  iris,  and  post- 
choroidal  hemorrhage  are  all  invited.  The  usual  method  is  by 
puncture  and  counterpuncture,  though  not  always.  Streatfeild, 
for  instance,  would  employ  a  rather  broad  Graefe  or  Sichel  cataract 
knife,  force  it  as  far  as  practicable  into  the  anterior  chamber,  then 
extend  the  wound  to  the  requisite  length  by  cutting  in  the  withdrawal. 
Such  a  maneuver  necessitates  not  only  much  skill,  but  an  exception- 
ally docile  patient.  Somewhat  less  daring  is  a  mode  practised  by 
Dehenne,  which  is  quite  practicable  where  the  anterior  chamber 
is  shallow  and  but  a  small  incision  is  desired.  This  consists  in 
entering  the  outer  limit  of  the  anterior  chamber  with  a  narrow 
30 


466  OPERATIONS  UPON  THE  GLOBE 

Graefe  knife  from  a  point  1.5  mm.  back  of  the  limbus,  and,  as  soon 
as  the  point  appears  in  front  of  the  iris,  extending  the  cut  for  four 
or  live  mm.,  parallel  with  the  corneal  border,  by  a  steady  motion 
which  is  a  compound  of  pushing  and  sawing.  To  prevent  torsion 
of  the  globe  the  grasp  of  the  fixation  forceps  must  be  close  up  to  the 
place  where  the  incision  begins. 

To  obtain  an  incision  of  sufficient  length  in  an  eye  whose  anterior 
chamber  is  lacking,  has  taxed  the  ingenuity  of  the  ocular  surgeon 
severely,  and  has  given  rise  to  a  number  of  experiments  that  are,  for 
the  most  part,  no  less  perplexing  than  the  original  problem  itself. 
To  cite  a  few: 

Brundenell  Carter^  advised  making  a  small  puncture  at  each  of 
the  spots  marking  the  extremities  of  the  incision  and  joining  them 
by  means  of  the  blunt  bent  keratome  of  Desmarres,  introduced 
first  at  one  puncture,  then  at  the  other. 

The  late  Prof.  Gayet,-  of  Lyons,  has  supplied  what  is  probably 
the  most  practicable  method.  The  globe  is  firmly  fixed,  close  to 
the  site  of  the  proposed  incision,  by  the  double  fixation  forceps  of 
Monoyer.  The  cut  is  made  with  the  Desmarres  scarificator.  The 
convex  edge  is  placed  at  the  sclero-corneal  junction,  with  the  blade 
set  at  about  the  angle  which  is  given  to  that  of  the  lance-knife  in  an 
ordinary  iridectomy,  and  the  penetration  is  achieved  by  slowly 
sawing,  meanwhile  maintaining  the  same  inclination  and  keeping 
parallel  with  the  limbus.  As  soon  as  a  drop  of  aqueous  appears  at 
any  part  of  the  cut,  the  scarificator  is  put  aside  and  the  incision  is 
finished  by  means  of  small  blunt-pointed  scissors.  Dianoux,^ 
proposed  a  modification  of  this  method  which  consisted  in  substi- 
tuting a  Beer's  cataract  knife  for  the  scarificator  and-a  Weber  probe- 
pointed  lacrimal  knife  for  the  scissors.  A  better  instrument  than 
either  of  the  last  two — one  less  likely  to  wound  the  iris — would 
seem  to  be  a  small  model  of  the  Desmarres  keratome. 

Burnett,'*  of  Washington,  in  cases  of  acute  glaucoma,  when  the 
anterior  chamber  is  abolished,  and  the  iris  is  reduced  to  a  narrow 
rim  or  is  lost  sight  of  beneath  the  scleral  border  of  the  cornea, 
proceeds  as  follows:  By  means  of  a  rather  short  stout  Graefe  knife, 
held  at  right  angles  to  the  surface  of  the  globe,  the  incision  is  ac- 
comi)lished,    from    without,    by   successive    strokes    of    the    point. 

'  Lancet,  vol.  ii,  p.  561,  1875. 

2  Bull.  ct.  niLin.,  soc.  frang.  d'opht.,  1S84,  p.  41. 

» Ibid.,  ]).  44. 

*  Am.  Journal  of  ( )p]il]ialnioloi;y,  April,  i{)02. 


GRASPING    AM)    WITHDRAWING  467 

The  curve  of  the  cornea  is  followed  for  a  distance  commensurate 
with  the  extent  of  the  opening  desired,  and  as  far  back  as  is  needful 
to  insure  the  most  peripheral  position  of  the  wound.  The  bottom 
of  the  cut  thus  carefully  made  Imally  gives  way,  at  some  ])oint, 
evinced  by  a  gush  of  aqueous,  and,  usually,  a  prolapse  of  iris.  At  this 
point  is  introduced  a  bulbous  pointed,  triangular  knife  (Fig.  275), 
and  section  of  the  already  thinned  tissue  is  completed.  Burnett  aptly 
observes  that  bleeding,  which  in  this  location  would  otherwise  prove 
embarrassing,  is  prevented  by  the  instillation  of  adrenal  solution. 
(B)  Grasping  and  Withdrawing  the  Iris.— These  acts  are 
executed  by  some  form  either  of  forcej^s  or  hook.  For  uncomi)li- 
cated  iridectomies,  the  forceps  is  usually  preferred.  The  general 
model  conforms  to  the  original  instrument  of  F.  Jaeger,  of  \'ienna. 


Fig.  275. — Burnett's  probe-pointed  keratome. 

being  of  delicate  make  and  with  extremities  of  limbs  more  or  less 
curved.  As  few  surgeons  now  employ  any  but  toothed  iris  forceps, 
the  special  feature  of  its  construction  has  reference  mainly  to  the 
arrangement  of  the  teeth,  which  is  a  matter  of  choice  on  the  part  of 
the  operator.  This  appears  to  be  about  evenly  divided  between 
those  with  the  teeth  placed  mesially  of  the  jaws  and  those  situated 
posteriorly,  called,  respectively,  middle-toothed  and  back-toothed. 
In  both  instances  the  teeth  are  even  with  the  tip  of  the  blades,  and, 
in  case  of  the  back-toothed  variety,  they  are  also  flush  with  the 
nether  edge  of  the  tip.  It  is  only  in  those  instruments  peculiarly 
designed  for  grasping  the  adherent  and  the  funnel-shaped  iris,  and 
in  the  capsule  forceps,  that  the  teeth  project  beyond  or  below  the 
edge.  These  are  not  safe  instruments  for  simple  iridectomy,  on  ac- 
count of  the  risk  to  the  lens,  though  invaluable  in  their  proper  sphere. 
The  rotary  forceps  of  Liebreich  and  Mathieu,  after  which  was 
patterned  the  forceps-scissors  of  De  Wecker,  are  excellent  for  use  with 
incisions  of  limited  extent,  since  they  admit  of  wide  opening  of  the 
jaws  without  separation  of  the  blades.  The  lirst  have  their  teeth 
in  the  middle,  the  second  at  the  back.  They  arc.  moreover,  the 
safest  forceps  with  which  to  go  after  a  second  bit  of  iris  when  the 
first  piece  excised  is  deemed  inadequate.     Many  operators  seem 


468  OPERATIONS  UPON  THE  GLOBE 

undetermined  as  to  the  breadth  to  which  the  iris  should  be  seized, 
to  regulate  which  Kuhnt^  invented  a  forceps  with  adjustable  stop, 
which  can  be  set  for  a  broader  or  a  narrower  grasp — especially 
useful,  as  in  optic  iridectomy,  when  a  narrow  or  small  coloboma 
is  wanted.  The  writer's  preference  is  for  the  back-toothed  kind, 
and  for  correct  model  of  the  instrument  the  reader  is  referred  to 
the  chapter  on  Instruments  and  their  Manipulation.  By  it  the  iris 
is  readily  laid  hold  of  with  a  minimum  of  bearing  down  and  tilting 
forward. 

In  making  an  iridectomy  where  there  is  exclusion  of  the  pupil  it 
is  important  that  the  bite  of  the  iris  forceps  includes  the  adherent 
portion,  or  the  sphincter — in  such  a  way  as  to  pucker  it  up  here  into 
radiating  folds,  the  better  to  loosen  it  from  the  capsule,  before  at- 
tempting to  withdraw.  The  iris,  in  these  cases,  is  usually  atrophied, 
and  very  fragile,  and  to  grasp  it  in  the  non-adherent,  or  ciliary  zone, 
one  risks  to  tear  it,  and  leave  the  adherent  portion  as  a  bridge. 

Iris  hooks  are  of  two  kinds — sharp  and  blunt.  The  first  is  for 
engaging  the  tissue  of  the  membrane  itself  for  withdrawal,  the 
second  to  catch  its  pupillary  border.  The  sharp  hook  (of  Beer) 
has  been  abandoned  because  of  its  danger  to  the  lens  and  its  faculty 
for  becoming  entangled  within  the  anterior  chamber.  The  blunt 
hook,  the  invention  of  Himly,  though  commonly  attributed  to  Tyrell,  is 
still  used  to  some  extent.  It  is  particularly  useful  for  iridectomy 
in  the  aphakial  eye.  In  one  respect  it  has  the  advantage  over  the 
forceps,  in  that  its  grasp  is  practically  painless,  while  that  of  the  for- 
ceps is  decidedly  the  reverse.  One  of  its  greatest  disadvantages  lies 
in  the  fact  that  it  cannot  be  made  to  let  go  promptly  in  an  emergency. 
Singularly  enough,  this  fault  is  due  to  a  virtue  in  its. construction, 
seeing  that  to  be  effective,  the  bend  must  be  sharp  and  of  fair  depth. 
The  blunt  hook  has  the  further  advantages  of  easy  manipulation 
through  a  very  small  incision  and  of  holding  the  iris  by  a  tiny 
area,  which  is  favorable  in  dosing  the  extent  of  the  excision. 

(C)  Size  and  Shape  of  the  Coloboma. — The  manner  of  grasp- 
ing the  iris  with  the  forceps,  that  is,  the  precise  location  of  the  part 
seized,  and  its  dimensions,  must  depend  largely  upon  the  object 
of  the  iridectomy.  In  the  vast  majority  of  the  uncomplicated 
iridectomies  the  lesser  circle,  or  corona,  is  the  most  eligible  objective 
'])oint.  The  somewhat  greater  elevation  and  thickness  of  this 
portion  of  the  iris,  together  with  the  looseness  of  its  tissue,  afford 

»Centralbl.  f.  A.,  1879,  S.  138. 


SEIZING    THE    IRIS  469 

a  safe  and  ready  hold.  For  a  sphinclereciomy  and  for  iridcclomy 
in  exclusion  of  the  pupil,  when  one  would  avoid  leaving  a  bridge, 
the  bite  of  the  forceps  must  be  as  near  as  practicable  to  the  pupillary 
border.  It  is  possible  in  making  sphincterectomy  to  grasj)  the 
iris  at  the  outer  limits  of  the  lesser  circle,  withdraw  till  the  free 
border  appears  without,  then  cut  in  front  of  the  tip  of  the  forceps 
but  this  mode  is  uncertain  and  not  to  be  recommended.  In  iridec- 
tomy for  glaucoma,  the  point  of  seizure  is  usually  about  midway 
of  the  membrane,  or,  to  be  more  technical,  toward  the  inner  limit 
of  the  ciliary  zone,  in  order  that  the  ligamentatum  peclinatum 
may  the  better  be  put  upon  the  stretch  to  insure  the  most  peripheral 
coloboma.  The  ciliary  zone  is  also  the  portion  selected  for  the  tiny 
forceps-bite  in  the  optic  iridectomy  of  Pope  and  in  the  drain  iridec- 
tomy of  Chandler — the  last  being  described  under  "Extraction." 
In  all  instances  in  which  the  excision  of  the  iris  is  made  with  a 
single  snip  of  the  scissors,  the  section  removed  embraces  the  part 
held  in  the  jaws  of  the  forceps,  and,  in  addition,  a  strip  of  varying 
width,  in  proportion  as  much  or  little  of  the  iris  is  drawn  out  at  the 
wound,  and  as  the  blades  of  the  scissors  approach  the  cornea.  The 
size  of  the  coloboma,  therefore,  in  the  one-snip  iridectomy,  with  a 
given  corneal  incision,  will  depend  upon  the  breadth  of  the  bite 
given  to  the  forceps,  the  extent  to  which  the  iris  is  withdrawn 
and  the  manner  of  manipulating  the  scissors  in  making  the  cut. 
Accurate  dosage  of  the  excision  is  not  possible  without  close  atten- 
tion to  each  of  these  three  features.  For  a  narrow  coloboma  with 
converging  pillars  the  said  bite  is  small,  little  more  than  the  sphincter 
is  withdrawn,  and  the  cut  is  made  with  scissors  blades  at  right  angles 
to  the  lips  of  the  wound  and  without  hugging  the  cornea  very  closely. 
For  a  broader,  more  peripheral  iridectomy,  the  bite  is  wider,  the 
withdrawal  is  more  pronounced,  and  the  snip  is  made  while  holding 
the  scissors  blades  parallel  with  the  lips  of  the  wound,  even,  if  need 
be,  pressing  them  down  at  the  moment  of  closing  upon  the  iris, 
in  order  to  make  a  yet  larger  section.  A  convenient  form  of  colo- 
boma for  preparatory  iridectomy  and  the  kind  most  suitable 
in  the  ordinary  therapeutic  iridectomy  in  acute  glaucoma  is  the 
"key-hole  coloboma"  of  Sir  WiUiam  Bowman.  This  is  made  bv 
three  snips  of  the  scissors,  and  in  this  manner :  As  the  iris  is  withdrawn 
it  is  pulled  to  one  extremity  of  the  corneal  incision,  the  pillar  of  that 
side  is  formed  by  a  snip  with  the  points  of  the  scissors,  the  latter 
directed  toward  the  root  of  the  iris;  the  membrane  is  then  more 


47°  OPERATIONS  UPON  THE  GLOBE 

Strongly  withdrawn,  the  base  of  the  coloboma  is  formed  by  a  snip 
parallel  with  the  lips  of  the  corneal  wound,  the  iris  is  then  pulled 
to  the  other  extremity  of  the  incision,  and  the  second  pillar  of  the 
coloboma  is  formed  by  the  third  and  final  snip  which,  like  the  first, 
is  directed  at  right  angles  to  the  course  of  the  corneal  incision.  This 
snij),  however,  is  not  made  with  the  points  of  the  blades  only, 
but,  to  the  end  that  the  severance  of  the  iris  may  be  complete,  the 
blades  are  placed  well  astride  the  protruding  iris.  In  each  cut 
the  scissors  are  held  close  down  to  the  surface  of  the  globe,  but 
not  in  such  a  manner  as  to  cut  the  conjunctiva.  For  the  extra 
broad  and  peripheral  coloboma  in  glaucoma,  Bowman^  recommended 
tearing  the  base  of  the  coloboma,  instead  of  cutting  it,  cutting  only 
the  pillars,  a  procedure  that  has  been  attributed  also  to  De  Wecker 
and  to  Cuignet  under  the  name  of  arrachement  of  the  iris.  This 
tearing  away  of  the  iris  in  iridectomy  for  glaucoma  has  several 
advantages.  It  admits  of  an  absolutely  peripheral  coloboma  \\\\\\ 
a  long  wound  canal,  whether  said  length  is  the  result  either  of 
beginning  of  the  primary  incision  well  back  of  the  sclero-corneal 
junction,   or  of   making   too   slanting   a   wound   in  attempting  to 


Fig.  276. — Not  possible  to  make  peripheral  coloboma  with  either 
incision  without  tearing  the  base. 

clear  the  iris  with  the  keratome  (Fig.  276).  The  anatomic 
arrangement  of  the  tissues  at  the  base  of  the  iris  is  such  as  to  cause 
the  rent  naturally  to  occur  in  the  most  favorable,  i.e.,  the  most 
peripheral  situation,  viz.,  in  the  cribriform  portion  of  the  ciliary 
zone  of  the  iris.  Indeed,  it  is  not  difficult  by  this  method  to  make 
a  coloboma  whose  lateral  dimensions  exceed  the  length  of  the  primary 
incision,  and,  on  occasion,  one  whose  base  is  more  peripheral  than 
are  the  inner  lips  of  the  incision.  With  a  good  bite  of  the  forceps, 
near  the  mid-zone  of  the  iris,  it  is  easy  to  tear  the  entire  membrane 
from  its  attachment  to  the  annular  ligament.  It  is  well  to  bear  in 
mind  the  frailty  of  this  fastening.     Another  condition  that  adds 

'  Trans.  London  Congress,  1873,  p.  203. 


ACCIDENTS    IN'    IRIDECTOMY  471 

to  the  efficiency  of  tearing  the  base  of  the  colol)oma  is  that  there  is 
usually  less  bleeding  than  from  cutting.  In  case  of  an  overhanging 
inner  lip  or  partial  splitting  of  the  cornea,  it  is  best,  as  soon  as  the 
forceps  has  secured  the  necessary  substantial  hold  upon  the  iris, 
to  start  the  tear  by  pushing  the  instrument  toward  the  center  of 
the  cornea,  as  it  will  then  yield  more  readily  than  ])y  drawing  the 
iris  at  once  into  the  wound. 

Accidents  During  the  Operation  of  Iridectomy. — Something 
untoward  can  occur  at  any  step,  from  the  beginning  of  the  incision 
to  the  completion  of  the  toilet.  Taken  in  their  order,  those  most 
likely  to  happen  are: 

I.  Faulty  Incision. — This  has  reference  to  the  placing,  the 
direction,  and  the  extent.  If  the  wound  lies  decidedly  within  the 
clear  cornea,  it  is  objectionable  in  nearly  every  form  of  iridectomy. 
In  the  optical  form  the  scar  might  encroach  too  much  upon  an 
important  transparent  area.  In  glaucoma  the  drawbacks  of 
such  a  wound  are  obvious,  for,  as  has  been  seen,  both  incision  and 
coloboma  must  here  be  peripheral.  Then,  too,  the  further  removed 
the  incision  from  the  sclera,  the  more  liable  it  is  to  gape.  On 
the  other  hand,  in  no  instance  ought  the  wound  to  be  further  back 
than  is  sufficient  to  admit  of  its  inner  lips  occupying  the  extreme 
outer  limit  of  the  anterior  chamber.  That  such  should  be  the  case, 
however,  especially  when  there  is  considerable  lack  of  said  chamber, 
the  outer  lips  of  the  incision  will  be  anywhere  from  i  to  3  mm. 
behind  the  apparent  sclero-corneal  junction.  Faulty  direction 
may  be  due  to  a  movement  on  the  part  of  the  patient,  as,  for  example, 
turning  backward  of  one  edge  of  the  keratome  into  the  ciliary 
body  or  forward  into  the  cornea.  This  is  particularly  liable  to 
happen  while  endeavoring  to  extend  the  incision  in  withdrawal 
of  the  knife.  Hence,  a  timely  word  of  caution  to  the  patient,  I'lrm 
fixation  of  the  globe,  and  a  steady,  deliberate  manipulation  of  the 
knife  are  the  best  preventives.  The  defect  in  direction,  however, 
that  is  most  frequent  is  the  interlamellar  incision — also  referred  to 
as  split  cornea  and  pocket  incision.  This  is  usually  consequent  upon 
the  mistaken  judgment  of  the  operator.  In  his  anxiety  lest  he 
engage  the  iris,  and  possibly  the  lens,  the  knife  either  utterly  fails 
to  enter  the  anterior  chamber  or  does  so  through  a  cut  so  slanting 
that  the  inner  wound  opening  is  far  from  the  periphery  and  the 
proper  grasping  of  the  iris  is  difhcult  or  impossible.  If  one  is 
confronted  with  the  first  dilemma,  of  course  the  aqueous  does  not 


472  OPERATIONS  UPON  THE  GLOBE 

escape,  and  he  has  but  to  withdraw  the  knife  and  begin  over,  this 
time  with  more  discernment.  But  if  the  chamber  is  opened  and 
the  iris  safe  from  seizure  beneath  the  shelving  nether  lip  of  the  wound, 
the  iridectomy  must  be  postponed  for  a  time.  An  insufficient  hold 
of  the  globe  by  the  fixation  forceps  may  lead  to  splitting.  At  the 
moment  one  attempts  to  make  the  puncture,  mayhap  with  a  knife 
none  too  keen,  the  considerable  force  required  causes  the  grip  of 
the  forceps  to  yield,  and  the  eye  to  rotate  away  from  the  knife, 
thus  changing  the  original  plane  of  the  incision  to  one  of  a  grade 
less  steep.  The  making  of  a  pocket  in  the  cornea  is  usually  evinced 
by  a  peculiar  opacity  which  surrounds  the  advancing  point  of  the 
knife.  The  obstacles  offered  by  too  small  an  incision  mainly  concern 
the  opening  of  the  iris  forceps,  and  may  be  sometimes  overcome 
by  substituting  the  rotary  forceps  or  the  blunt  hook.  If  neither 
serves,  the  incision  must  be  extended  by  blunt-pointed  scissors 
(Stevens'  strabotomy  scissors),  or  by  some  such  instrument  as 
Desmarres'  blunt  pointed  keratome.  Given  a  lance-knife  with  a 
blade  at  once  relatively  hroad  and  short,  a  cornea  relatively  thick, 
and  a  wound  canal  not  of  the  shortest,  and  it  is  easy  to  obtain  an 
insignificant  inner  wound  opening  with  a  fairly  long  external  one. 
Should  one  suspect  such  a  state  of  affairs,  a  slight  rocking  of  the 
knife  from  side  to  side  just  before  its  withdrawal  will  result  in 
enlargement  of  the  inner  opening. 

2.  Engaging  the  Iris  with  the  Knife. — This  comes  (a)  of 
failure  to  alter  the  plane  of  the  blade  to  one  parallel  with  that  of  the 
iris  the  moment  the  point  has  entered  the  anterior  chamber,  or  {b) 
from  piercing  the  sclera  so  far  back  and  so  squarely  that  the  knife 
encounters  the  iris  before  entering  the  anterior  chamber;  or  (c) 
because  of  hugging  the  front  surface  of  the  iris  rather  than  the 
back  surface  of  the  cornea  in  pushing  forward  the  blade.  The 
prevention  in  each  instance  is  obvious.  If  a  occurs  and  is  detected 
immediately,  the  knife  may  be  very  slightly  pulled  back  and  faintly 
wiggled  to  disengage.  If  the  involvement  is  more  pronounced 
and  withdrawal  necessitates  emptying  of  the  anterior  chamber, 
the  operation  would  better  be  deferred.  If  h  happens,  the  iris 
begins  to  tear  from  its  attachment  the  moment  the  point  enters  it, 
and  if  the  operator  is  not  led  to  suspect  the  accident  by  the  non- 
appearance of  the  point  at  the  expected  time  and  place,  iridodialysis, 
or  grave  injury  to  the  lens,  or  both,  may  ensue.  At  best,  it  means 
postponement  of  the  operation.     In  the  event  of  being  confronted 


ACCIDENTS    IX    1R11)K(  TOM  V  473 

by  c,  if  one  is  closely  observant  of  the  prof^ress  of  the  knife  and 
the  patient  is  quiet,  the  point  may  be  promptly  freed  as  soon  as  it 
catches,  as  suggested  for  a,  its  direction  changed  to  a  safer  plane  and 
the  section  completed.  If  for  any  reason  the  entanglement  is 
such  as  to  necessitate  escape  of  the  aqueous  in  trying  to  free  it, 
and  so  peripheral  as  to  make  certain  an  extensive  iridodialysis  by 
forging  ahead,  it  were  best  the  operation  be  put  off.  It  is  only  in 
case  of  picking  up  the  iris  at  the  lesser  circle  with  the  extreme  tip 
of  the  blade  that  one  might  risk  tilting  back  the  handle  to  avoid 
the  lens  and  pushing  forward  a  short  distance,  even  at  the  expense 
of  a  small  rent  of  the  iris,  with  the  view  to  enlarging  the  incision 
afterward.  These  points  have  reference  to  the  use  of  the  lance- 
knife.  Those  relative  to  that  of  the  Graefe  knife  are  given  under 
"Accidents  During  Extraction." 

A  rare  accident  that  can  happen  to  a  novice  using  a  small  keen 
keratome,  and  one  apt  to  prove  most  disastrous,  is  the  shoving  of 
the  blade  bodily  .nto  the  anterior  chamber.  I  have  seen  it  occur 
only  in  student  operations  upon  pigs'  eyes. 

3.  Too  Sudden  Evacuation  of  the  Aqueous. ^This  is  an 
occurrence  of  much  graver  import  than  is  commonly  admitted. 
The  usual  result  of  the  rush  of  the  fluid  is  that  the  iris  is  carried 
with  it  into  the  wound,  which,  of  itself,  is  bad  enough;  but,  worse 
yet,  the  abrupt  lowering  of  the  intraocular  pressure,  even  when  not 
previously  high,  may  give  rise  to  choroidal  hemorrhage  and  to 
rupture  of  the  zonule  and  hyaloid,  with  presentation  of  vitreous  or 
subluxation  of  the  lens.  So  slightly,  however,  has  the  accident  been 
regarded  that  many  operators,  following  the  example  of  Bowman, 
have,  in  certain  simple  iridectomies,  regularly  practised  quickly 
jerking  out  the  knife  with  the  express  purpose  of  causing  a  prolapse 
of  the  iris,  in  order  to  be  spared  the  necessity  of  drawing  out  the 
iris  with  a  traction  instrument.  The  custom  s  much  to  be  deprecated, 
for,  aside  from  the  danger  just  mentioned,  what  one  gains  in  readily 
seizing  the  protruding  membrane  is  more  than  counterbalanced 
by  the  unavoidable  lack  of  precision  in  properly  fashioning  the 
coloboma  under  such  conditions — in  giving  it  due  symmetry, 
and  in  dosing  the  excision.  For  these  reasons  Czermak  strongly 
advises  replacing  the  prolapse  before  proceding,  so  that  the  seizure 
and  withdrawal  may  be  accomplished  in  the  regulation  way.  He 
makes  exceptions,  however,  as  follows: 


474  OPERATIONS  UPON  THE  GLOBE 

1.  When  the  conjuncliva  is  so  inflamed  as  lo  entail  danger  of 
infection. 

2.  When  the  tension  is  high. 

3.  When  the  lens  is  (hslocated  or  abnormally  small,  as  in  hydroph- 
thalmos,  or  when  the  vitreous  is  presenting. 

4.  In  cases  of  nervous  persons  and  children,  operated  under  local 
anesthesia. 

True  enough,  a  prolapse  can  be  brought  about  by  other  means 
than  by  carelessness  in  removing  the  knife,  such  as  pressure  upon 
the  globe  by  fixation  forceps,  movement  or  squeezing  upon  the  part 
of  the  patient,  etc.  Having  occurred,  whether  or  not  an  attempt 
should  be  made  to  replace  it  before  making  the  excision  must  be 
left  to  the  discretion  of  the  surgeon.  In  spite  of  the  utmost  pre- 
caution on  the  surgeon's  part  and  the  most  praiseworthy  conduct  on 
that  of  the  patient,  a  prolapse  will  sometimes  follow  the  knife. 
This  is  particularly  true  of  iridectomy  in  eyes  whose  tension  is 
raised. 

4.  Iridodialysis,  other  than  that  produced  by  engaging  the  iris 
with  the  keratome,  may  happen  because  of  an  unexpected  move- 
ment of  the  patient  while  the  iris  is  in  the  grasp  of  the  forceps,  and 
as  a  result  of  a  too  peripheral  seizure  of  the  membrane.  It  is  im- 
portant, therefore,  that  one  try  to  prevent  the  one  by  gentle  words 
of  encouragement  to  the  patient  and  by  anticipating  his  motions, 
and  to  avoid  the  other  by  a  suitable  hold  upon  the  iris. 

5.  Leaving  behind  a  pupillary  bridge  is  not  always  intentional 
or  desirable.  It  ensues  most  often  through  failure  to  draw  the 
sphincter  well  out  before  cutting  off  the  iris.  Again,  where  exists 
posterior  synechia,  it  may  come  of  grasping  the  iris  too  far  from  the 
free  border,  or  it  may  be  inevitable  on  account  of  the  firmness  of  the 
adhesion.  A  bridge  that  is  free  can  best  be  dealt  with  by  means  of 
the  blunt  hook.  The  blepharostat  is  removed,  a  pad  of  cotton,  wet 
with  boric  solution  is  laid  on  the  closed  lids  for  a  few  minutes  while 
the  anterior  chamber  is  partially  reestablished.  This  facilitates 
the  manipulation  of  the  hook.  The  eye  is  opened.  The  blepharo- 
stat is  replaced,  the  globe  fixed,  the  hook  inserted,  flatwise,  at  the 
incision,  the  bridge  deftly  caught,  so  as  not  to  wound  the  lens,  the 
hook  again  turned  flat,  brought  out,  and  the  strip  of  iris  severed. 
A  tightly  adherent  l)ri(lge  would  better  be  left  unmolested. 

6.  Leaving  the  uveal  lining  of  the  excised  portion  adherent  to 
the  anterior  caj^sule  is  an  unavoidable  accident  in  complete  posterior 


ACCIDENTS    IN    IRIDECTOMY  475 

synechia.  Whetlier  the  object  of  the  iridectomy  is  optic  or  thera- 
peutic, the  only  alternatives,  in  this  connection,  are  to  leave  the  eye 
to  its  fate  or  to  extract  the  lens.  If  the  eye  be  glaucomatous,  the 
extraction  would  better  be  made  at  once,  first  enlarging  the  corneal 
incision,  then  making  free  capsulotomy  in  the  area  occupied  by  the 
pupil  and  the  pigmented  coloboma.  Should  the  tension  be  normal, 
further  operating  would  better  be  postponed.  For  self-protection, 
in  no  case  will  the  suri^eon  fail  to  obtain  beforehand  the  patient's  con- 
sent— or  its  equivalent — to  an  extension  of  the  measure  originally 
proposed. 

7.  Wounding  of  the  anterior  capsule  is  a  grave  casualty  when 
the  lens  is  transparent  and  in  elderly  individuals  with  opaque  lenses 
and  glaucoma,  since  it  leads  in  many  cases  to  cataract  or  to  forced 
extraction  to  prevent  loss  of  the  eye.  It  is  serious  in  any  case.  It 
is  due  to  some  fault,  preventable  or  otherwise,  in  the  management 
of  the  knife,  the  forceps,  or  the  spatula.  It  is  the  extremity  of  each 
of  these  instruments  that  it  behooves  one  to  watch.  The  use  of 
forceps  with  sharp  teeth  projecting  beyond  the  posterior  edge  of  the 
jaws  is  most  hazardous.  The  spatula  should  be  well  curved  and  of 
nicely  rounded  end. 

8.  Rupture  of  the  Zonule. — Aside  from  the  too  sudden  evacua- 
tion of  the  aqueous,  w^hich  has  already  (third)  been  mentioned  as  a 
cause  of  the  accident,  it  may  also  result  from  too  great  pressure 
upon  the  forceps  in  grasping  the  iris,  from  sudden  movement  of  the 
eye  while  handling  either  forceps  or  spatula,  and  from  external 
pressure  by  patient  or  operator.  It  is  highly  unfortunate,  whatever 
the  kind  of  iridectomy.  In  the  preparatory  it  complicates  the  ex- 
traction and  often  induces  loss  of  vitreous;  in  the  optic  and  the 
therapeutic  it  may  give  rise  to  escape  of  vitreous,  to  cataract,  to 
secondary  glaucoma,  or  to  a  worse  form  of  glaucoma  on  top  of  one 
already  bad  enough.  In  other  words,  malignant  glaucoma  may 
follow  an  iridectomy  for  a  milder  form  of  the  disease  if,  through  sub- 
luxation of  the  crystalline,  the  periphery  of  that  body  becomes 
jammed  in  between  the  ciliary  processes  and  the  canal  of  Schlemm. 
Methods  have  been  devised  whereby  to  replace  lenses  thus  dis- 
located, as,  for  example,  that  of  De  Wecker,^  which  consists  in 
making,  after  lirm  union  of  the  corneal  wound,  his  anterior  sclerot- 
omy on  the  side  opposite  that  of  the  coloboma,  then,  while  the  cor- 
nea is  still  transfixed  by  the  knife,  essaying,  by  means  of  pressure 

1  LaChirurgie  oculaire,  p.  155. 


476  OPERATIONS  UPON  THE  GLOBE 

of  the  thumb  through  the  intervening  M,  to  force  the  lens  back  into 
position.  Such  procedures  are  mostly  unsatisfactory.  It  were 
better  one  trusted  to  immediate  or  subsequent  extraction  did  the 
exigencies  of  the  case  seem  to  demand  it.  Should  the  lens  become 
actually  engaged  in  the  corneal  wound,  be  it  cataractous  or  not, 
it  should  be  extracted  at  once. 

9.  Bursting  of  the  hyaloid  usually  attends  any  considerable 
rupture  of  the  zone  of  Zinn  and  from  the  same  causes.  When  it 
occurs  before  the  excision  of  the  iris,  the  latter  is  likely  to  be  rendered 
difficult.  The  only  indication  of  the  break,  perhaps,  is  the  sudden 
deepening  of  the  anterior  chamber,  more  marked  on  the  side  where 
the  incision  is  situated,  provided  the  iris  has  not  followed  the  knife 
into  the  wound.  The  backward  slant  of  the  iris,  suspended  in 
vitreous,  makes  the  use  of  the  forceps  for  its  withdrawal  impracti- 
cable, so,  unless  a  spontaneous  prolapse  has  taken  place,  the  blunt 
or  sharp  hook  must  be  substituted.  Should  the  vitreous  present 
at,  or  escape  from,  the  wound  before  the  withdrawal  of  the  iris,  it 
would  be  well  to  postpone  the  operation  save  in  the  event  of  most 
pressing  need  of  an  iridectomy.  As  soon  as  it  is  evident  that  the 
hyaloid  has  given  way,  all  extraneous  pressure  upon  the  globe  is 
quickly  reduced  to  the  minimum,  and  the  eye  is  closed.  Blepharo- 
stat, fixation  forceps,  etc.,  are  discarded.  If  it  is  decided  to  go 
ahead  with  the  excision,  an  assistant  retracts  the  lids  with  instru- 
ments or  with  his  fingers.  If  the  pupillary  border  of  the  iris  is 
visible,  it  is  grasped  with  the  blunt  hook,  if  not,  one  may,  when  sure 
of  his  hand,  attempt  to  seize  the  membrane  with  the  sharp  hook, 
catching  in  the  stroma  just  where  it  is  folded  backward.  It  is  worse 
than  useless,  however,  to  try  to  get  the  iris  out  when  it  is  completely 
introverted.  In  cases  where  the  luxation  of  the  lens  is  discovered 
prior  to  the  operation  or  where  loss  of  vitreous  is  feared,  the  writer 
would  recommend  the  Angelucci  fixation,  i.e.,  grasping  the  tendon- 
ous  portion  of  the  superior  rectus,  as  described  under  "Extraction." 
A  trained  assistant  is  necessary.  As  the  surgeon  completes  the 
primary  section,  the  helper  takes  from  him  the  knife  and  gives  the 
traction  instrument — forceps  or  hook.  Then,  as  the  surgeon  pulls 
out  the  iris,  the  assistant  is  ready  with  the  scissors  to  cut  it  off,  which, 
having  been  accomplished,  the  hold  on  the  tendon  is  released  and 
the  lids  closed.  Of  course,  the  fixation  forceps  has  no  catch.  This 
is  one  of  the  few  instances  where  the  keratome  with  bayonet  shank 
may  be  found  serviceable. 


ACCIDENTS    IN    IRIDECTOMY  477 

lo.  Blood  in  the  Anterior  Chamber. — This  comes  from  the 
cut  or  torn  iris  or  from  the  incised  conjunctiva.  Bleeding  is 
always  more  profuse  when  the  eye  is  under  the  secondary  effect 
of  either  cocain  or  adrenal  solution.  Blood  in  the  anterior  chamber 
is  chiefly  objectionable  when  it  accumulates  to  considerable  degree 
directly  the  incision  is  finished,  in  that  it  conduces  to  faulty  technic 
in  the  remaining  steps.  It  can  often  be  got  out  and  ought  to  be, 
when  possible,  before  proceeding,  by  the  methods  described  under 
"Immediate  Accidents  in  Extraction."  A  thin  layer  of  blood  lying 
between  cornea  and  iris  after  the  operation  is  concluded  is  of  no 
consequence,  for  it  will  soon  be  absorbed,  but  if  a  greater  quantity 
be  present,  it  should  not  be  ignored  lest  the  resulting  clot  might 
serve  as  the  starting-point  of  a  new  growth  within  the  anterior 
chamber. 

With  regard  to  the  consecutive  accidents  in  connection  with 
iridectomy,  they  are,  in  the  main,  such  as  are  treated  of  under 
"Extraction,"  and  need  no  repetition  here.  Given  a  fairly  healthy 
eye  and  a  normal  iridectomy,  with  keratome  or  bent-lance  incision, 
done  under  the  conditions  demanded  by  modern  ideas,  and  few 
operations  in  eye  surgery  are  attended  with  less  risk  in  the  after- 
treatment.  The  corneal  wound  closes  in  most  instances  by  primary 
union,  and  great  restriction  of  the  patient's  liberty  is  not  needful. 
After  iridectomy  for  glaucoma,  on  the  other  hand,  a  binocular 
bandage  and  the  utmost  quiet  that  is  consistent  v/ith  safety  to  the 
circulatory  system  are  indispensable.  These  things  are  all  the 
more  to  be  insisted  upon  if  the  wound  does  not  close  promptly. 
Tardy  closure  of  the  incision  after  iridectomy  for  glaucoma — par- 
ticularly the  subacute  or  intermittent  variety — is  something  to 
be  dreaded;  more  so  than  after  the  ordinary  extraction,  for  all 
the  good  that  might  otherwise  accrue  to  the  eye  can  be  thereby 
nullified.  The  pillars  of  what  had  been  an  ideal  coloboma  are 
swallowed  up,  and  the  anterior  chamber  is  definitively  abolished. 
The  muchlauded  "filtration  scar"— that  is,  one  that  is  truly  effec- 
tive in  keeping  the  intraocular  tension  within  bounds — is  no 
more  apt  to  follow  delayed  than  immediate  closure  of  the  in- 
cision. In  short,  the  more  quickly  the  anterior  chamber  is  reestab- 
lished, the  better. 

A  second  iridectomy  is  occasionally  required  in  a  glaucomatous 
eye.  It  is  the  practice  of  most  surgeons  to  make  the  new  coloboma 
but  a  continuation  of  the  old — an  extension,  as  it  were. 


478  OPERATIONS  UPON  THE  GLOBE 

ENUCLEATIOX. 

Enucleatio  bulbi ;  excision  of  the  globe;  shelling  out   the 

eyeball  are  terms  in  good  usage  for  a  surgical  procedure  whereby 
the  naked  bulbus  is  severed  from  its  attachments  and  removed 
from  the  orbit.  The  first  recorded  attempt  at  such  an  operation 
was  that  of  Lange,i  but  the  precise  method  is  not  given.  George 
Bartisch,  of  Konigsbruck,  Saxony,  a  contemporary  and  survivor 
of  Lange,-  soon  after  removed  an  eye  that  was  in  a  state  of  procidence 
and,  still  later,  described  the  mode  of  operating.  He  used  a  small 
razor-shaped  knife;  with  this  he  cut  and  scraped,  following  the 
sclera,  and  loosening  it  from  all  connection  with  surrounding  tissues. 
In  a  case  of  cancerous  growth  affecting  the  bulbous  and  neighboring 
structures,  Bartisch  made  exenteration  of  the  orbit,  having  recourse 
to  a  sort  of  spoon,  with  sharp  edges,  taking  great  care  to  preserve 
the  eyelids.  Fabrice  de  Hilden^  instead  of  the  razor  knife,  em- 
ployed in  a  similar  way  a  straight,  double-edged,  bulbous-pointed 
knife,  which  he  introduced  through  the  opening  caused  by  a  previous 
circumcorneal  dissection  of  the  conjunctiva.  Louis  substituted 
for  the  knife  blunt  scissors,  curved  .on  the  flat,  the  instrument  that 
has  since  been  used.  Notwithstanding  the  value  of  the  operation 
of  enucleation  it  fell  into  oblivion,  from  which  it  was  not  resurrected 
till  near  the  middle  of  the  19th  century.  The  classic  method  of 
ablation  of  the  globe,  on  which  are  based  all  of  those  practised  to- 
day, is  that  proposed  and  described  by  Bonnet,'*  of  Lyons,  as  a 
result  of  his  studies  of  Tenon's  capsule.  This  procedure  was 
first  put  into  practice  by  Stoeber,  of  Strassburg,  in  1842,  and  its 
technic  was  largely  refined  by  While  Cooper,  of  Loadon,  in  185O. 
Panas  says:  ''The  principal  merit  of  Bonnet's  operation  is  the 
conservation  of  Tenon's  capsule,  which  admits  of  the  extirpation 
of  the  globe  without  injury  to  the  soft  i)arts  of  the  orbit."  Briefly 
described,  it  is  as  fol  ows: 

The  eye  having  been  properly  prepared  and  the  blepharostat  put 
in  place,  the  conjunctiva  all  around  the  cornea  is  detached  by 
means  of  scissors  and  freed  from  its  episcleral  attachments.  The 
four  rectus  tendons  are  hiid  bare,  hfted  in  succession  upon  a  l)lunt 
strabismus  hook,  and  divided  with  curved  scissors,  even  with  the 

'  Thema.  Cliir.  Fi}j;uri.  1555,  j).  313. 
2  Augendicnst  Drcsticn,  1583. 
'Observation.  Chirurj,'.,  Frankfort,  164.6. 
♦  Annal.  d'oculist,  T.  v,  1841.  ]).  27. 


ENUCLEATION  479 

sclera.  This  done,  the  j^lobe  is  dislocated  forward,  the  scissors 
passed  behind  it,  and  the  optic  nerve  is  severed  slightly  back  of  its 
junction  with  the  sclera.  The  globe  is  now  held  well  forward, 
with  the  fingers,  while  the  tendons  of  the  obliques  and  the  few 
remaining  attachments  are  cut. 

Slight  modifications  of  this  oj)eration  or  a  much  altered  form  of 
it  devised  by  Von  Arlt,^  of  Vienna,  constitute  the  methods  now 
practised,  and  they  are  referred  to  as  the  Bonnet  and  as  the  Vienna 
methods.  In  the  Von  Arlt  enucleation  the  hook  is  dispensed  with. 
An  assistant  usually  holds  the  lids  apart  with  the  Desmarres' 
retractors.  We  will  suppose  the  right  eye  is  to  be  removed.  The 
operator  stands  at  the  patient's  right  side.  With  the  forceps  a 
fold  of  conjunctiva  is  picked  up  in  the  horizontal  meridian,  close 
to  the  nasal  limbus  of  the  cornea,  and  snipped.  The  blunt  point  of 
a  pair  of  small  curved  scissors  is  put  through  the  opening,  the 
conjunctiva  is  incised  all  around,  save  for  a  small  bridge  at  the 
temporal  side,  then  dissected  from  the  sclera  and  shoved  well  back. 
The  tendon  of  the  internus  is  seized  with  the  forceps,  and  thus  held 
throughout  the  rest  of  the  operation.  The  blunted  scissors  blade 
is  slid  beneath  the  tendon,  and  the  latter  is  cut  back  of  the  forceps. 
The  globe  is  rotated  downward,  the  scissors  inserted  beneath  the 
superior  tendon,  which  is  ch'vided  flush  with  the  sclera.  The  eye 
is  rotated  upward,  and,  in  similar  manner,  the  inferior  tendon 
is  severed.  The  globe  is  now  rotated  somewhat  outward,  while 
the  closed  scissors  are  passed  behind  it  at  the  nasal  side  to  locate 
the  optic  nerve,  then  opened  to  cut  it.  The  bulbus  is  lifted  out  of 
its  socket,  the  obliques  are  detached,  and,  lastly,  the  externus,  the 
bridge  of  conjunctiva,  and  all  remaining  connections  are  cut  away. 

Agnew's  Method. — The  mode  of  enucleating  that  has  always 
commended  itself  most  strongly  to  the  author  is  a  phase  of  the 
Bonnet  operation  adopted  by  the  late  C.  R.  Agnew,  of  New  York. 
I  have  never  seen  a  published  description  of  this  procedure,  but  my 
conception  of  it  and  mode  of  making  it,  from  having  seen  Dr. 
xAgnew  perform  it  a  number  of  times,  is  here  given.  The  instru- 
ments required  are  blepharostat  (or,  better,  ])ro\i(led  an  efficient 
aid  is  available,  Desmarres,  retractors),  fixation  forceps,  without 
catch,  mouse-tooth  forceps,  Stevens'  strabismus  scissors,  a  ])air  of 
stronger  blunt   scissors,  curved  on    the  llat,  and    two  medium-size 

^Zeitsch.  (ler  Wiener  Aerzte,  i^sg,  and  Ilamlb.  von  Graefe  und 
Saemish,     1874. 


48o 


OPERATIONS    UPON    THE    GLOBE 


Graefe  squint  hooks,  neatly  flattened  and  rounded.  The  operator 
stands  facing  the  top  of  the  patient's  head,  as  in  extraction,  and  it 
does  not  comport  with  elegance  to  change  one's  position  from  start 
to  finish  if  one's  training  will  warrant  it.  On  causing  the  lids  to  be 
held  apart,  if  a  general  anesthetic  be  employed,  as  is  usually  the 
case,  the  globe  will  be  found  strongly  rotated  upward.     The  object 


Fig.  277. — First  step  in  Agncw's  enucleation. 


of  having  the  I'lxation  forceps  at  hand  is  to  rotate  the  eye  in  the 
opposite  direction  while,  with  the  other  forceps,  a  substantial 
meridional  fold  of  conjunctiva  and  episcleral  tissue  is  picked  up 
near  the  upper  corneal  border  (Fig.  277).  This  is  snipped  with  the 
Stevens  sci.ssors  between  forceps  and  cornea,  and  from  the  opening 
thus  made  the  conjimctiva  is  incised  so  as  to  completely  encircle  the 
cornea,  the  forceps  all  the  while  maintaining  the  first  hold.     By 


ENUCLEATION 


481 


first  sliding  a  blade  of  the  scissors  beneath  the  conjunctiva  as  close 
as  practicable  to  the  cornea  then  working  it  toward  the  limbus  with 
a  sort  of  riving  motion,  the  incision  can  be  made  very  close  to  the 
base  of  the  cornea.  Still  holding  the  bile  of  the  forceps  the  con- 
junctiva is  undermined  for  a  few  mm.  all  round,  and  the  anterior 
prolongation  of  Tenon's  capsule  is  likewise  incised.  Still  keeping 
the  grasp  of  the  forceps,  the  scissors  are  exchanged  for  a  hook  which 
is  inserted  beneath  the  tendon  of  the  superior  rectus,  and,  thereafter, 
one  hook  or  tlie  other  serves  to  fix  the  globe.     The  forceps  is  laid 


Fig.  27S. — Severing  tendon  of  externus  in  enucleation. 


aside,  the  hook  shifted  to  the  left  hand,  the  scissors  again  taken,  the 
conjunctiva  and  capsule  pushed  back  to  expose  the  caught-up 
tendon,  and  the  latter  severed  by  cutting  from  heel  toward  point  of 
hook.  Before  freeing  the  point,  however,  and  allowing  the  eye  to 
roll  upward  again,  and  without  dropping  the  scissors,  the  second 
hook  is  inserted.  In  this  way  the  hooks  and  scissors  are  carried 
around  the  spiral,  and  continuous  line  of  insertion  of  all  the  recti 
muscles,  never  letting  go  with  one  hook  till  the  other  is  in  place. 
It  is  the  aim  to  always  leave  enough  tissue  engaged  by  the  tip  of 
the  hook  to  serve  for  fixation  while  the  second  hook  is  being  inserted; 
but  should  the  instrument  be  cut  entirely  free,  it  is  easy  enough  to 
31 


482 


OPERATIONS    UPON    THE    GLOBE 


reinsert  it  without  first  fixing  the  globe.  The  operator  can  work 
from  right  to  left,  as  move  the  hands  of  a  clock,  or  in  the  opposite  di- 
rection, or  in  both  directions.  When  it  comes  to  division  of  the  tendon 
of  the  externus  it  should  be  cut  at  least  one-eighth  inch  from  the  sclera 
so  that  the  stumj)  will  later  serve  as  a  handle  (Fig.  278).  In 
most  cases  the  tendons  of  the  two  obliques  can  now  be  caught  and 
detached  previous  to  the  neurectomy,  or  they  can  be  left  alone  until 


Fig.  279.— StM 


•nni;  tnc  opticus 


after  ihc  nerve  is  divided.  A  hook  is  then  swe[)l  around  to  search 
for  stray  fibres.  The  strong  scissors  here  replace  the  other  instru- 
ments, the  globe  is  dislocated  slightly  forward  by  pressing  the  lids 
backward,  and  steadied  by  the  fingers;  the  closed  blades  are 
carefully  insinuated  between  ca])sule  and  sclera,  at  the  temporal 
side,  and  worked  back  to  feel  for  the  optic  nerve.     Having  found 


ENUCLEATION  483 

what  seems  to  be  the  object  sought,  one  slides  the  scissors  above  it 
and  presses  down,  then  below,  and  presses  up.  If  it  be  the  ner\e, 
the  globe  will  turn  up,  then  down,  in  obedience  to  the  i:)ressure. 
It  only  remains  to  draw  back  slightly,  open  the  scissors  moderately, 
and  then  achancc  so  as  to  include  the  opticus  ])etween  the  blades. 
Before  cutting,  it  is  well  to  again  press  down  and  up  to  be  sure,  by 
the  mo\ements  of  the  eye,  that  the  blades  are  really  astride.  A 
single  lirm  snip,  and  the  globe  jumps  forward  followed  by  an  extra 
gush  of  blood  (Fig.  279).  It  is  best  now  to  terminate  the  operation 
quickly.  The  globe  is  grasped  firmly  in  the  fmgers  of  the  left  hand 
or  the  stump  of  the  externus  is  seized  with  the  fixation  forceps,  and 
one  proceeds  to  divide  whatever  else  is  still  adherent.  If  the  bleeding 
is  not  excessive,  the  socket  is  copiously  irrigated  with  hot  sublimate 
solution,  when  the  fiow  is  promptly  checked.  The  opening  in  the 
conjunctiva  is  neatly  drawn  shut — not  sutured — and  any  extruding 
shreds  from  the  tissues  beyond  are  cut  off. 

Other  Modifications. — There  is  another  French  method  worthy 
of  mention.  It  is  that  of  Tillaux,  and  is  called  enucleation  from 
behind  forward.  After  dissection  of  the  conjunctiva  the  tendon  of 
the  externus  is  severed  at  a  little  distance  from  its  insertion.  The 
stump  of  tendon  is  seized  with  fixation  forceps,  the  globe  strongly 
rotated  inward,  and,  with  the  curved  blunt  scissors,  the  opticus  is 
divided.  Still  held  by  the  forceps,  the  globe  is  drawn  out  through 
the  conjunctival  opening,  when  it  is  easy  to  detach.  Hush  with  the 
sclera,  the  five  remaining  tendons.  Cunier  made  the  operation  in 
reverse  manner,  i.e.,  starting  with  the  internus. 

A  Simplified  Method  of  Enucleation. — Menacho,  ]\I.,  Bar- 
celona. (A7/;/.  Mon.  fur  Aug.,  XL\TII,  April,  1910,  p.  460).  The 
alterations  of  the  technic  proposed  by  Menacho  aim,  first,  to  render 
enucleation  easier;  second,  to  remove  a  large  portion  of  the  optic 
nerve  for  preventing  relapses  of  neoplasms  or  propagation  of  sym- 
pathetic ophthalmia;  third,  for  easier,  and  more  complete,  micro- 
scopic examination  of  the  optic  nerve.  After  peritomy  the  conjunc- 
tiva is  detached  as  far  as  the  equator  and  the  internal  and  external 
recti  cut,  10  mm.  from  their  insertions.  A  thick  silk  suture  is  placed 
through  both  tendinous  stumps  and  tied  t(3  a  loop,  which  is  given 
to  an  assistant  for  fixation.  Thus  the  two  other  recti  and  the  optic 
nerve  can  be  cut  better.  If  the  eyeball  is  pulled  forward  by  the 
thread  the  optic  nerve  can  be  cut  at  the  optic  foramen.  The  method 
insures  greater  guaranty  for  the  success  of  the  operation. 


484  OPERATIONS  UPON  THE  GLOBE 

E.  Meyer^  carefully  abstains  from  cutting  or  loosening  the  sub- 
conjunctival tissue  in  the  region  of  the  insertions  of  the  recti.  To 
make  a  passage  for  the  hook,  he  incises  the  mucosa  alongside  each 
muscle,  that  is,  in  the  interval  of  each  one  of  the  insertions.  More- 
over, in  order  to  preserve  the  union  between  the  muscle  and  their 
capsular  envcloi)s,  he  lifts  the  tendon  and  shaves  it  from  the  surface 
of  the  sclera.  Lastly,  to  augment  the  lateral  movements  of  the 
prothesis,  he  closes  the  opening  in  conjunctiva  and  capsule  by  several 
sutures  placed  vertically. 

With  the  idea  of  increasing  the  movement  of  the  stump  left  after 
enucleation,  De  Wecker,  some  twenty-five  years  ago,  after  the 
pericorneal  incision,  put  in  a  tobacco-pouch  suture  that  included 
conjunctiva,  capsule,  and  tendons  of  the  recti.  He  then  proceeded 
to  excise  the  globe  by  the  Bonnet  method,  and  fmished  by  drawing 
up  and  tying  the  suture.  This  bringing  together  of  the  tendons 
with  their  aponeuroses  intact  would  seem  to  be  an  improvement, 
with  respect  to  control  of  the  prothesis,  over  the  earlier  and  simpler 
operations.  The  arrangement  of  the  threads  has  been  subjected 
to  various  alterations.  One  of  the  latest  and  best  is  that  of  Hansell 
and  Sweet.-  "After  dissecting  the  conjunctiva  from  the  limbus, 
each  straight  muscle,  together  with  the  overlying  conjunctiva  and 
capsule  of  Tenon,  is  firmly  grasped  by  the  fixation  forceps  and 
separately  sutured  by  single  threads,  before  dividing  the  tendons 
from  the  sclera.  After  enucleation  of  the  ball  and  the  checking  of 
the  hemorrhage,  the  cut  edges  of  the  conjunctiva,  with  the  muscles 
and  capsule  are  brought  together  over  the  muscle  bed  by  two  or 
three  sutures."  The  sense  in  which  the  sutures  are  directed  is 
not  specified,  but  as  lateral  movement  is  more  to  be-  sought  in  the 
artificial  eye  than  is  vertical,  and  as  this  movement  depends,  in  a 
measure,  upon  the  conservation  of  the  conjunctival  cul-de-sacs,  to 
place  the  sutures  vertically,  thus  closing  the  opening  into  a  hori- 
zontal line,  will  act  to  deepen  the  lateral  cul-de-sacs  at  the  expense 
of  those  above  and  below. 

In  a  series  of  five  papers  published  in  the  O phlhalmic  Record  for 
November,  1908,  it  appears  that  there  have  come  to  light  18  cases  of 
sympathetic  ophthalmia  following  Mules'  operation ;  i.e.,  the  insertion 
of  some  sort  of  ball  within  the  sclera.     These  include  the  original 

1  Bull,  et  mem.  de  la  soc.  fram;-.  d'opht.,  1898,  p.  185. 
*  Diseases  of  the  Eye,  Phila.,  1903,  p.  283. 


INTRACAPSULAR  I'ROTIIESIS  485 

13  collected  by  Cross,  and  5  since  reported,  namely,  one  each  by 
Sherman,  Emerson,  Gifford,  Oliver,  and  Brobst. 

The  same  source  furnishes  4  cases  of  sympathetic  ophthalmia 
following  Frost's  operation,  i.e.,  implantation  of  a  ball  of  some 
material  in  Tenon's  capsule,  one  each  by  Cant,  Lang,  Sattler,  and 
Davis. 

Also  nine  cases  of  the  disease  after  evisceration  without  artificial 
vitreous,  namely,  one  each  by  Dransart,  Waldispuhl,  Van  Duyse, 
Forget,  Hotz,  Nieden,  and  De  Wecker,  and  two  by  Schmidt-Rimpler. 

Forget's^  case  can  hardly  be  included  as  it  was  one  of  "optic 
neuritis  occurring  19  months  after  evisceration,"  nor  can  Hotz's,^ 
for  it  was  one  of  ''mild  optic  neuritis  3  weeks  after  evisceration,  and 
recovered  without  removal  of  the  stump." 

Since  the  operation  of  evisceration  came  into  vogue  there  have 
been  reported  36  cases  of  sympathetic  ophthalmia  coming  after 
enucleation. 

In  view  of  the  fact  that  all  ophthalmic  surgeons  and  some  who 
are  not  make  enucleations,  and  that  the  vast  majority  of  hem 
make  exenterations  (of  some  kind),  the  few  unfortunate  results 
just  quoted  in  connection  with  these  two  measures  are  of  little 
consequence.  Especially  is  this  true  of  evisceration,  when  one 
considers  that  many  of  the  so-called  eviscerations  have  not  resulted 
in  the  thorough  cleaning  out  of  the  scleral  cavity,  and  many  others, 
in  which  although  this  cleaning  out  may  have  been  thorough,  have 
finished  by  the  tying  of  a  purse-string  suture  or  of  some  other  kind 
that  caused  strangulation  of  the  circulation  of  the  conjunctiva  and 
that  of  Tenon's  capsule,  thus  producing  intense  inflammatory 
reaction. 

On  the  other  hand,  in  view  of  the  relatively  small  number  of 
surgeons  who  have  made  the  Mules'  and  Frost's  operation,  the 
showing  is  bad  indeed  for  those  procedures. 

Intracapsular,  or  Intratenonian  Prothesis. — In  1887 
Frost  and  Lang,-^  simultaneously  conceivctl  and  carried  out  the 
idea  of  implanting  the  glass  ball  of  Mules  in  the  fibrous  capsule  of 
the  globe,  after  enucleation.  Since  that,  glass  having  shown  a 
decidedly  effective  propensity  for  extricating  itself,  other  sub- 
stances have  been  employed.  Although  the  relatively  few  advocates 
of  the  measure  out  of  the  many  who  have  tried  it  have  expressed 

1  Arch,  d'oph.,  p.  693. 

-Trans.  Oph.  Sec.  Am.  Med.  Assoc,  1893,  P-  93- 

■'  Brit.  Med.  Jour.,  vol.  i,  pp.  1043  and  1153. 


486  OPERATIONS  UPON  THE  GLOBE 

themselves  as  eminenlly  satisfied  with  their  resuhs,  a  glance  at  a 
partial  list  of  the  different  materials  with  which  it  has  been  attempted 
to  replace  tlie  living  bulbus  is  not  calculated  to  strengthen  their 
position  in  tlie  matter: 

Glass Frost.  Rubljer Pick. 

Celluloid     Lang.  Wire   Landman. 

Sponge Belf.  Silk         1    Bourgeois. 

Peat Bourgeois.  Catgut   J 

Ti  r  Livin"  1  T  Fat  from  gluteal 

B^"^^   {  Decalcified  /         Lagrange.  ^^^-^^     Barraquier. 

Agar-agar    Suker.  Skin  and  adipose  from 

Vaselin     Rohmer.  gluteal  region Rollet. 

G°'^      P""^^-  Rabbit's  eye {  B-d^f-^ 

Paraffin    Brockaert. 

Paraflin  is  the  latest  aspirant  for  honors  in  this  line.  In  an  in- 
teresting article  in  Knapp's  Archives  for  March,  1905,  Spratt,  of 
Minneapolis,  reports  23  cases  in  which  spheres  of  this  kind  were 
used,  with  only  one  known  failure  from  extrusion.  The  idea  is 
conveyed,  however,  that  from  first  to  last  these  cases  had  been 
under  observation  for  a  period  of  only  seven  months.  The  paraffin 
was  of  the  melting-point  of  60  degrees  C.  (140  degrees  F.),  made  into 
balls  about  17  mm.  in  diameter.  The  operation  is  as  follows: 
After  the  pericorneal  incision  and  dissection  each  of  the  rectus 
tendons  is  caught  fast  by  a  Halsted  "mosquito"  hemostat.  One 
then  proceeds  to  divide  the  tendons  and  enucleate  in  the  usual  way. 
The  paraffin  ball  is  placed  in  Tenon's  capsule  with  common  forceps. 
The  tendons  of  the  opposing  muscles  are  stitched  together  over 
the  paraffin  by  mattress  sutures  of  chromicized  catgut,  Tenon's 
capsule  and  the  conjunctiva  are  closed  by  purse-string  sutures;  the 
first  of  ordinary  catgut  and  the  second  of  silk.  The  writer  of  the 
article  warns  against  spheres  too  large,  and  against  undue  tension 
upon  the  sutures.     The  advantages  claimed  for  paraffin  are: 

1.  It  is  non-irritating,  hence  least  likely  to  be  extruded. 

2.  The  spheres  can  be  made  easily  and  arc  inexpensive. 

3.  No  danger  of  being  broken. 

4.  The  ]3araffin  adapts  itself  to  the  shape  of  the  cavity,  is  soon 
surrounded  by  a  fibrous  capsule,  and  is  firmly  held  in  place  by 
connective  tissue  down-growths. 

Abundant  exj)ericnce  has  demonstrated  that  the  inorganic  sub- 
stances, such  as  glass  and  metal,  introduced  in  the  cavity  of  Tenon 
are  generally,  sooner  or  later,  eliminated,  while  those  of  organic 
or   living  tissue,  linis  sej)araled    from  their  natural   environment, 


IMPI.AXTATIOX    METHODS  487 

althoui^^h  grafting  well  in  this  location,  unfortunately,  in  time, 
undergo  so  great  a  retraction  that  there  remains  of  them  but  an 
insignificant  trace.  Paraffin  is  treacherous  in  that  it  is  prone  to 
change  its  location  even  when  not  expelled.  Dr.  Chibret,  of 
Clermont-Ferrand,  conceived  the  original  idea  of  replacing  the 
enucleated  eye  by  that  of  the  pig — ^^  Idee  Audacieusey  Jkil  it 
succeeded,  in  a  measure.  Then  Prof.  Rohmer,  of  Nancy,  after 
having  made  several  implantations  of  the  eyes  of  animals  in  the 
peritoneal  cavity,  with  positive  results,  grafted  in  man,  in  case  of 
a  blind  subject,  whose  eye  was  lost  from  iridocyclitis  and  enucleated, 
an  eye  of  the  rabbit  in  Tenon's  capsule.  But  after  2  weeks  the 
implant  was  eliminated,  and  Rohmer,  discouraged,  gave  up  the 
experiment.  Then  Prof,  Lagrange,  without  knowledge  of  Rohmer's^ 
experience,  undertook  the  same  researches,  published  in  1901, 
with  encouraging  results.  In  his  first  article  and  in  another, 
published  in  La  Clinique  O phtalmologique,  1901,  he  declared  that 
the  result  depends  solely  upon  the  choice  of  method  that  is  made 
for  the  operation.  Some  years  afterward,  in  1905,  Lagrange 
made  to  the  French  Society  of  Ophthalmology  at  Paris  a  new 
communication  upon  the  subject.  Wicherkiewicz,  of  Krakow, 
was  present  and  saw  the  patients  operated  upon  by  Lagrange, 
and  listened  to  the  discussion  which  occurred.  It  was  Rohmer  who 
then  declared  that,  in  time,  all  these  transplanted  eyes  undergo 
complete  absorption.  He  contended  that  Lagrange  would  soon 
be  disillusioned,  and  would  return  to  the  transplantation  of  balls 
of  paraffin. 

Operation  of  Lagrange. — He  used  silk  threads  to  unite  the 
severed  tendons.  After  enucleating  the  eye  he  employed  iced 
compresses  to  arrest  the  hemorrhage.  He  then  introduced  the 
eye  of  a  rabbit,  of  appropriate  size,  the  cornea  backzcard.  Over  this 
the  recti  tendons  were  united,  in  opposing  pairs,  and,  lastly,  the 
conjunctival  opening  was  closed  by  sutures.  The  predecessors 
of  Lagrange — Chibret,  Rohmer,  Terrien  and  Bradfort — gave  to 
the  transplanted  eye  its  normal  orientation,  i.e.,  cornea  forward, 
which  sometimes  led  to  disaster,  such  as  ulceration,  perforation,  and 
loss  of  vitreous. 

The  divergence  of  opinion  of  his  eminent  confreres  caused 
Wicherkiewicz,-  to  undertake  to  satisfy  himself  personally  as  to 

1  Annates  d'Oculistique,  iii. 

2  L'Ophthalmologie  Provinciate,  March,  1909. 


400  OPERATIONS  UPON  THE  GLOBE 

the  value  of  this  form  of  transplantation.  In  consequence,  Wicher- 
kiewicz  and  his  assistants  made  35  implantations,  with  a  technic 
somewhat  modified  from  that  of  Lagrange.  He,  like  Lagrange, 
placed  the  eye  in  the  inverse  position,  which  is  better  for  the  nutrition 
of  the  cornea.  He  used  catgut  to  unite  the  recti  tendons.  The 
Tenonian  cavity  was  first  irrigated  with ,  cold,  sterile,  physiologic 
salt  solution.  Fifteen  were  children.  In  32  instances  chloroform 
narcosis  was  employed,  and  in  3  local  (Schleich's),  with  novocain 
and  adrenalin.  These  last  reacted  much  more  severely  than  did 
the  chloroform  cases.  In  24  cases  there  was  no  marked  reaction. 
In  a  few  instances  the  threads  cut  out  of  the  tendons,  necessitating 
their  renewal.  Once  there  was  copious  hemorrhage  beneath  the 
conjunctiva.  In  two  pronounced  exophthalmos  occurred,  the 
result  of  deeper  hemorrhage.  In  eleven  there  was  considerable 
edema  of  the  conjunctiva.  Wicherkiewicz's  operations  demon- 
strated that  the  eye  of  the  rabbit  "takes"  readily  in  its  new  soil. 
As  an  illustration  of  the  intimacy  of  its  union  with  its  surround- 
ings, in  one  of  Wicherkiewicz's  cases  the  original  eye  had  been 
removed  because  of  a  malignant  tumor,  the  growth  recurred  and 
penetrated  to  the  interior  of  the  new  eye.  It  was  also  demon- 
strated that  the  grafted  eye  progressively  lost  volume  in  all  cases, 
and  that  this  atrophic  process  was  most  marked  in  the  older 
subjects,  in  whom  it  did  not  cease  until  the  graft  disappeared 
completely;  while,  as  regarded  the  children,  it  remained  of  fair 
size,  even  at  the  end  of  two  years.  For  these  reasons  Wicher- 
kiewicz  now  limits  the  operation  to  children  and  to  those  adults 
who  are  in  urgent  need  of  an  enucleation,  but  will  only  consent  to 
undergo  it  by  being  promised  that  another  eye  will  be  put  in  to 
replace  that  which  is  sacrificed.  In  children,  who  are  too  young 
to  wear  an  artificial  eye,  the  grafted  eye,  according  to  Wicherkiewicz, 
serves  to  fill  the  socket,  prevents  falling  in  of  the  free  borders  of  the 
lids,  obviating  irritation  from  the  lashes,  favors  development  of 
that  side  of  the  face,  and  prevents  the  ugly  sinking  backward  of  the 
upper  lid  and  the  formation  of  the  deep  orbito-palpebral  furrow. 

Enucleation.— General  Considerations  as  to  Technic— If 
one  is  blest  with  a  trained  assistant,  the  operation  of  enucleation  is 
greatly  facilitated  by  entrusting  to  him  the  opening  of  the  lids  by 
means  of  a  pair  of  Desmarres'  tractors.  He  knows  just  how  to 
follow  the  course  of  the  operator  with  the  points  of  widest  separa- 
tion of  the  lids,  now  widening  the  palpebral  fissure   most  exter- 


ENUCLEATION  489 

nally,  now  internally;  now  lifting  high  the  u|)])ct  lid  while  casing 
up  on  the  lower,  and  vice  versa,  always  guarding  the  free  borders 
from  a  snip  of  the  scissors.  In  the  absence  of  such  help,  the  Mel- 
linger  blepharostat  serves,  by  reason  of  the  |)arallcl  opening  of  its 
lid-holders,  as  the  best  substitute. 

Detaching  the  Recti. — It  is  in  respect  to  this  feature  that  the 
Arlt  method  departs  farthest  from  that  of  Bonnet.  For  the  few 
uncomplicated  cases  where  the  relations  of  the  parts  are  normal, 
the  Vienna  mode,  without  squint  hooks,  offers  to  the  skilled  surgeon 
an  opportunity  for  exceedingly  brilliant  work — an  excision  of  the 
globe  in  a  little  more  than  one  minute,  and  with  the  use  of  but  two 
instruments.  But  for  less  experienced  operators,  and  for  the  more 
difficult  cases,  such  as  shrunken  or  flabby  globes  and  those  charac- 
terized by  inflammatory  processes,  with  adhesions  to  the  surround- 
ing tissues,  no  matter  how  clever  the  surgeon,  it  is  not  to  be  recom- 
mended. The  tendons  cannot  be  picked  up  so  easily  and  divided 
so  precisely  with  the  scissors  alone  as  with  both  hook  and  scissors, 
and  there  is  greater  liability  of  wounding  the  fibrous  capsule  of  the 
globe  which,  in  view  of  possible  infection  of  the  cellular  tissue  of 
the  orbit,  is  by  all  means  to  be  avoided.  The  Bonnet  method, 
as  modified  by  Agnew,  admits  of  nearly  or  quite  as  rapid  an  excision 
in  the  simpler  cases,  and  both  simplifies  and  hastens  matters  as 
regards  the  complex  ones.  When  the  tendons  can  be  readily  caught 
upon  the  hook,  no  other  fixation  of  the  globe  is  necessary,  but 
where  extensive  adhesions  exist,  one  may  either  leave  a  bit  of  tendon 
attached  as  a  hold  for  ordinary  fixation  forceps  or,  what  answers 
better,  have  recourse  to  the  tenaculum  forceps,  the  grip  of  whose 
talon-like  extremities  may  be  varied  at  will. 

Dividing  the  Opticus. — Most  writers  have  taught  that,  for  this 
purpose,  the  scissors  should  be  inserted  at  the  nasal  side,  arguing 
that  this  affords  the  shortest  route  to  the  nerve.  It  would  seem, 
however,  that  those  who  favor  the  external  route  have  decidedly 
the  advantage.  The  manipulating  of  instruments  at  the  temporal 
side  in  operations  upon  the  globe  is  always  handier  than  at  the 
nasal  side.  Then,  the  diverging  outer  wall  of  the  orbit  makes  the 
opticus  more  accessible  from  that  side.  Moreover,  as  the  larger 
blood-vessels  lie  more  to  the  nasal  side  there  is  less  risk  of  excessive 
hemorrhage  by  choosing  this  way.  It  is  not  advisable  to  rotate 
the  globe  strongly  to  bring  the  nerve  nearer  to  the  scissors  in  severing 
it,  as  this  is  apt  to  result  in  mangling  the  bottom  of  the  eye-socket, 


490 


OPERATIONS    UPON    THE    GLOBE 


in  oblique  section  of  the  nerve,  and  in  greater  wounding  of  blood- 
vessels, with  unnecessary  bleeding.  I  have  never  felt  the  need  of 
any  instrument  other  than  the  medium-sized  curved  blunt  scissors 
for  this  step  in  the  operation.  The  bifid  spoon  of  the  elder  Terson 
(Plate  \T1I)  and  the  hemostatic  clamp  attachment  for  the  scissors 
of  Warlomont  (Fig.  280)  sometimes  employed  in  this  connection 
having  always  struck  me  as  a  useless  augmentation  of  an  already 
adequate  apparatus;  therefore,  subversive  of  the  wholesome  rule 
that  the  fewer  the  instruments  the  better  —  always  provided  the 
results  are  in  no  way  prejudiced  by  too  scant  an  equipment.  If 
there  be  a  tumor  of  the  posterior  hemisphere  or  one  that  fills  the 
vitreous  chamber,  it  is  best  to  remove  as  much  of  the  opticus  as  is 


P'iG.  2S0. — Warlomont's  hemostatic  scissors. 


practicable.  The  same  is  true  of  cases  wherein  signs  of  impending 
sympathetic  ophthalmia  are  present  in  the  fellow  eye.  Knapp  is 
the  author  of  a  convenient  and  cflicient  mode  of  making  this  re- 
section. Before  cutting  the  nerve  he  passes  behind  the  globe  the 
closed  blades  of  a  delicate  pair  of  hemostatic  forceps,  curved  on  the 
fiat,  feels  for  and  seizes  the  nerve  a  few  mm.  behind  the  eye,  and 
locks  the  handles.  He  then  introduces  the  scissors  and  severs 
between  the  point  of  fixation  and  the  optic  entrance.  After  the 
bleeding  has  ceased,  the  nerve  is  (h'awn  forward  by  tlie  still  adhe- 
rent forceps,  and  as  much  cut  off  as  is  deemed  sufficient.  Indeed, 
when  the  enucleation  is  made  because  of  a  small  tumor,  and  in- 
spection of  the  section  of  the  opticus  shows  that  it  is  normal,  the 
force] )s  may  be  released  without  making  the  resection. 

In  this  jjrocedure  of  Kna])i)'s  the  fact  that  the  traction  is  on  the 
opticus  itself,  and  not  upon  ihc  glolx.',  as  with  the  'I'erson  instrument 


ENUCLEATION — IMMEDIATE    ACCIDENTS  49 1 

before  mentioned,  makes  it  all  the  more  to  be  commended.  Vur 
often  there  is  a  weak  spot  in  the  eye  to  be  enucleated  such  as  a  recent 
wound,  or  a  thinned,  or  it  may  be,  a  staphylomatous  area  in  the 
cornea,  which  could  readily  burst  open  by  the  increased  intraocular 
tension  caused  by  pressure  upon  the  globe  from  behind,  resulting  in 
escape  of  the  vitreous,  thus  complicating  the  operation  and  spoiling 
a  laboratory  specimen.  If  a  large  scleral  or  corneal  wound  exists 
it  were  a  wise  precaution  to  suture  it  firmly  before  beginning  the 
enucleation. 

Suturing  the  conjunctival  opening  accomplishes  no  special  good. 
Healing  is  as  safe  and  prompt  and  smooth  without  it.  Granulation 
buttons  seem  to  occur  about  as  often  with  as  without.  On  the 
contrary,  it  prolongs  the  operation,  increases  the  number  of  instru- 
ments, becomes  foul  with  the  discharges,  acts  like  a  seton  in  the 
tissues,  and  in  the  end  necessitates  an  operation  for  its  removal. 

IMMEDIATE  ACCIDENTS. 

1.  Perforating  the  Sclera. — This  is  most  likely  to  occur  in 
eyes  of  normal,  subnormal,  or  increased  tension  by  pulling  up  too 
strongly  on  a  tendon  while  detaching  it  from  its  insertion,  especially 
when  the  scissors  are  rather  pointed  or  are  made  to  hug  the  sclera 
too  closely;  and  in  eyes  of  reduced  tension  by  attempting  to  sever 
the  opticus  flush  with  its  entrance  while  making  undue  forward 
traction  upon  the  globe.  The  most  serious  objections  to  this  mishaj) 
are  that  it  embarrasses  the  subsequent  steps  of  the  operation  and 
that,  in  the  event  of  the  contents  of  the  eye  being  septic,  there  is 
danger  of  infection  of  the  tissues  of  the  orbit. 

2.  Hemorrhage. — While  in  most  instances  there  is  no  trouble 
from  this  source  in  excising  the  bulbus,  bleeding  is  sometimes 
copious  from  the  very  beginning  and  throughout  the  operation. 
That  from  the  conjunctiva  and  Tenon's  capsule  can  usually  be 
controlled  by  the  instillation  of  adrenal  solution  or  by  ilooding  the 
eye  with  hot  sterile  or  sublimated  water,  though  to  apply  the  adrenal 
solution  too  long  beforehand  only  tends  to  favor  the  flow  of  blood. 
It  is,  however,  upon  section  of  the  optic  nerve  and  surrounding 
vessels  that  the  worst  hemorrhages  are  to  be  apprehended.  This  is 
particularly  true  of  subjects  in  whom  there  has  been  marked  de- 
generation of  the  vascular  system.  One  should,  therefore,  exercise 
great  discrimination  in  making  this  section.  First,  take  care  not  to 
pop  the  eye  too  much  before  cutting,  thus  putting  the  posterior 


492  OPERATIONS  UPON  THE  GLOBE 

ciliary  arteries  too  greatly  upon  the  stretch,  so  that  after  their 
division,  their  distal  cut  ends  will  retract  behind  the  fibrous  capsule 
of  the  globe  and  convert  the  whole  orbit  into  an  enormous  hematoma. 
So  tense  can  the  tissues  become  from  this  cause  as  to  result  in 
necrosis  of  the  lids.  Secondly,  guard  against  shoving  the  blades  of 
the  scissors  too  far  astride  the  nerve,  thus  including  the  nasofrontal 
artery;  and  also  against  opening  the  blades  too  wide  and  making  the 
section  to  comprehend  large  branches  of  the  ophthalmic  vein  that 
might  be  otherwise  avoided.  Inexperienced  operators  are  too 
prone  to  grow  flustered  at  this  stage  of  an  enucleation  and  to  poke 
and  haggle  aimlessly,  deep  in  the  orbit,  provoking  needless  hemor- 
rhage. If  the  outward  escape  of  blood  from  the  empty  eye-cup  is 
excessive  or  prolonged,  it  is  best  to  tampon  the  cavity  with  wet 
(sublimate)  absorbent  cotton,  and  over  all  put  a  compressive 
bandage.  This,  be  it  observed,  is  but  temporary,  i.e.,  to  be  kept  in 
place  only  until  the  bleeding  ceases,  when  it  is  to  be  removed,  the 
tampon  taken  out,  the  cavity  washed,  the  conjunctival  opening 
neatly  arranged,  the  lids  closed  and  the  dressing  applied  in  the 
regulation  way.  No  foreign  substance,  such  as  cotton  or  sponge, 
must  ever  be  left  in  the  open  wound  long  enough  to  become  ad- 
herent. This  can  occur  in  a  comparatively  few  hours  and  can  prove 
extremely  vexatious.  It  is  rarely,  indeed,  that  more  strenuous 
measures  are  called  for,  such  as  the  application  of  sesqui-chlorid 
of  iron,  ligation,  or  the  Paquelin  cautery,  in  dealing  with  the 
hemorrhage. 

3.  Leaving  Part  of  an  Ocular  Tumor  in  the  Orbit.— If,  upon 
the  removal  of  an  eye  for  an  intraocular  tumor,  it  is  discovered  that 
the  growth  has  become  extraocular,  and  there  is  evidence  that  any 
portion  remains  behind,  it  must  be  sought  at  once  and  scrupulously 
excised.  The  same  also  as  regards  any  infiltration  of  the  optic 
nerve  by  a  neoplasm. 

4.  If  the  Globe  be  too  large  to  Pass  Through  the  Palpebral 
Fissure. — The  remedy  lies  in  a  free  external  canthotomy.  As 
soon  as  the  enucleation  is  completed,  the  divided  conjunctiva  and 
the  skin  are  to  be  separately  sutured  so  as  to  restore  them  to  their 
normal  condition. 

5.  Operating  Upon  the  Wrong  Eye.— That  this  most  deplorable 
accident  is  not  beyond  the  realm  of  the  possible  has  been  abundantly 
proven,  and  that  by  more  than  a  single  instance.  Although  one  of 
the  victims  thereof  may  be  tcrril)lv  cul])al)lc,  thcv  are  both  deserving 


EXUCLEATION—  CONSECUTIVE    ACCIDENTS  493 

of  our  sinccrcst  commiseration.  T.cl  c\cry  o]jhliialmic  surgeon  see 
to  it,  henceforth,  that  this  calamity  does  not  happen  through  fault  of 
his  or  through  that  of  anyone  else  connected  with  the  case.  Never 
trust  in  the  matter  to  those  who  prepare  the  jnitient  for  the  opera- 
tion. Examine  the  eye  immediately  beforehand.  If  the  one  to  be 
removed  has  no  conspicuously  distinguishing  external  feature — as 
in  intraocular  tumor — shave  the  brow  u])on  that  side,  or,  better 
still,  place  a  mark  upon  the  forehead  adjacent. 

COXSECUTIVE  ACCIDENTS. 

1.  Secondary  Hemorrhage. — This  is  a  contingency  against 
which  we  have  been  repeatedly  warned,  yet  one  that  seldom  arises. 
The  writer  has  never  encountered  it.  Unlikely  though  it  be,  one 
must  be  prepared  to  meet  it.  For  this  reason  it  is  best  to  have  the 
case  under  strict  surveillance  for  at  least  24  hours  after  the  operation. 
A  mere  sanguinary  staining  of  the  dressings  signifies  nothing. 
Should  it  be  discovered  that  blood  actually  trickles  from  beneath  the 
coverings  of  the  eye,  the  bandage  must  be  taken  off  and  measures 
instituted  tending  to  stop  the  flow^ced  compresses  to  the  lids,  hot 
sublimate  irrigation,  and  tamponment  of  the  open  socket,  with  re- 
application  of  the  compressive  bandage;  or,  if  need  be,  recourse  to 
the  more  extreme  ways  and  means  mentioned  under  "Immediate 
Accidents." 

2.  Infection. — Cellulitis  of  the  orbit,  ascending  meningitis,  and 
thrombophlebitis  of  the  ophthalmic  vein  and  its  adnexes  are  the 
truly  grave  sequels  that  enucleation  can  engender.  But  with  due 
regard  to  the  laws  of  modern  surgical  prophylaxis  and  to  the  in- 
tegrity of  the  protecting  fascia  of  the  orbital  tissues,  their  advent 
is  scarcely  to  be  apprehended.  There  are  three  main  factors  for  the 
prevention  of  the  accident  in  question  that  one  should  strive  to 
eliminate,  viz. :  unclean  implements,  needless  wounding  or  opening 
of  Tenon's  capsule  and  contamination  from  the  tissues  involved. 
The  first  is  accomplished  in  great  measure  by  thorough  boiling  of 
the  instruments  and  cleansing  of  the  hands;  the  second,  by  carefully 
dissecting  up  the  anterior  prolongation  of  the  capsule,  picking  up 
and  dividing  the  tendons  of  the  ocular  muscles  close  to  the  sclera 
with  the  least  disturbance  of  the  aponeurotic  wrappings,  and  the 
absolute  conservation  of  the  fibrous  capsule  that  envelops  the 
posterior  half  of  the  globe;  the  third,  by  the  free  use  of  antiseptic 
irrigation  and  the  preservation  of  the  walls  of  the  globe  (when  its 


494  OPERATIONS  UPON  THE  GLOBE 

contents  are  septic).     Here  it  may  be  again  remarked  that  exentera- 
tion may  be  often  substituted  with  greater  safety  for  enucleation. 

INDICATIONS  FOR  ENUCLEATION. 

These  may  be  arranged  in  three  groups:  i.  absolute  and  impera- 
tive; 2.  elective,  and  3.  optional. 

Absolute  indications  are  those  that  leave  no  choice  of  other 
means  of  treatment.  Among  them  are  the  cases  for  which  enuclea- 
tion affords  either  the  only  chance  or  hope  of  preserving  the  integrity 
of  the  fellow  eye  or  of  saving  the  life  of  the  patient.  To  this 
group  belong  the  following  classes : 

(a)  Eyes,  be  they  sightless  or  not,  that  are  causing  sympathetic 
irritation  or  the  actual  beginning  of  sympathetic  inflammation. 

(/;)  All  blind  eyes — and  in  this  connection  blind  means  hopelessly 
so — that  are  exciting  or  have  excited  sympathetic  inflammation, 
no  matter  what  the  stage  of  said  inflammation. 

(c)  All  eyes,  whether  sightless  or  not,  in  which  positive  diagnosis 
of  an  intraocular  malignant  tumor  has  been  made. 

{d)  All  blind  eyes  within  whose  walls  there  is  any  reason  to  suspect 
the  presence  of  a  malignant  growth. 

(e)  All  eyes,  sightless  or  not,  where  exists  an  epibulbar  malignant 
growth  that  it  is  not  practicable  otherwise  wholly  to  remove. 

(/)  All  blind  eyes  w^ith  epibulbar  malignant  growths,  regardless 
of  the  degree  of  involvement. 

(g)  Persistent  pain  referred  to  the  eye  after  exenteration  or  optico- 
ciliary neurectomy. 

(h)  Extreme  atrophy  of  the  globe. 

(i)  Grave  phlegmon  of  the  orbit  when  sight  is  utterly  destroyed 
and  the  o]:)eration  may  aid  in  curing  the  disease. 

Remarks  on  Group  i.  Class  a. — Ophthalmic  surgeons  are 
almost  a  unit  in  affirming  that  immediate  excision  of  the  globe, 
together  with  a  pretty  generous  section  of  the  optic  nerve,  constitute 
the  only  remedy.  There  are,  however,  a  number  of  men  whose 
word  is  authoritative,  who  would  place  these  cases  in  Group  2, 
as  admitting  of  a  choice  between  enucleation  and  exenteration  as 
the  means  of  dealing  with  them.  The  inflammation  having  become 
thoroughly  established  in  the  sympathizing  eye,  while  useful  vision 
is  still  possessed  by  the  exciting  eye,  then  the  question  as  to  the 
removal  of  the  latter  becomes  a  problem  the  solution  of  which 
must  be  left  to  those  who  have  the  case  in  charge,  as  it  opens  a  field 


KXUCT.KATIOX       1 NDICA  1  K  ).\S  495 

of  discussion  loo  wide  lo  have  a  place  here.  With  re;^ard  to  Class  c, 
if  the  tumor  is  manifestly  of  insignificant  proportions,  expccially 
if  its  exact  nature  is  not  known  beyond  peradventurc,  it  is  true  that 
the  excision  is  not  at  once  obligatory,  and  further  developments 
might  be  awaited  and  observed — indeed,  in  that  event  it  would 
not  really  belong  to  this  class.  Prominent  in  Class  (/  arc  those 
eyes  that  are  in  a  state  of  absolute  glaucoma.  It  would  be  good 
practice  to  enucleate  every  one  of  these  as  soon  as  possible,  lest 
hidden  therein  should  be  a  dangerous  sarcoma.  This  is  particularly 
true  when  the  other  eye  is  free  from  signs  of  glaucoma  and  the 
subject  is  of  middle  age  or  older.  To  make  iridectomy  or  any 
form  of  sclerotomy  for  the  relief  of  the  tension  or  pain,  and  with 
the  view  of  ''saving  the  eyeball,"  is  worse  than  folly  in  these  cases. 
Aside  from  the  hazard  of  a  lurking  tumor,  such  eyes  arc,  as  a  rule, 
better  out  than  /;/. 

Group  2.  Elective  Indications. — These  have  reference  to 
eyes  that  may  be  regarded  in  the  light  of  a  menace,  more  or  less 
imminent,  to  the  well-being  of  their  fellow,  yet  can  be  rendered 
impotent  for  harm  by  some  other  procedure,  as,  for  example,  the 
operation  of  exenteration,  as  well  as  by  that  of  enucleation.  They 
may  be  classiiied  thus: 

(a)  Recent  fresh,  extensive  injuries  seriously  involving  the 
ciliary  region. 

(b)  Eyes  blind  from  chronic  inflammations  of  the  uveal  tract. 

(c)  Phthisis  bulbi,  not  extreme,  with  or  without  calcific  or  osseo- 
calcific  degeneration  of  the  choroid. 

(d)  Total  extensive  staphyloma  of  the  cornea  or  of  the  globe. 

(e)  Blind  eyes  containing  inextricable  foreign  bodies. 
(/)  Acute  suppurative  panophthalmitis. 

Remarks.  Class  a.— It  is  remarkable  to  what  an  extent  the  tunics 
of  the  globe  may  be  wounded,  even  when  the  ciliary  body  is  included 
in  the  trauma,  yet  recover  promptly.  Provided  there  has  been  no 
infection,  and  reparation  has  been  rapid  and  complete,  so  long  as 
the  eye  remains  absolutely  quiescent,  plump,  and  of  normal  tension, 
it  is  not  only  safe  to  leave  it  in  place,  but  it  were  wrong  to  enucleate 
or  exenterate — irrespective  of  questions  of  sight  or  the  location  of 
the  original  wound.  Should  a  lingering  iridocyclitis  or  choroiditis 
result  with,  perhaps,  disturbances  of  tension,  and  sight  is  gone, 
excision    of    the    globe  or  exenteration    should    be    done  without 


496  OPERATIONS  UPON  THE  GLOBE 

further  delay.  Given  these  conchlions,  together  with  useful  vision 
and  a  wound  of  the  cihary  zone,  nothing  short  of  "  eternal  vigilance" 
on  the  part  of  one  capable  of  properly  observing,  could  be  an 
excuse  for  not  resorting  to  one  of  the  operations  named  the  moment 
it  was  found  that  other  modes  of  treatment  were  of  no  avail.  In  the 
writer's  opinion,  exenteration  is  better  suited  to  every  class  cited 
in  Group  2  than  is  enucleation. 

Group  3.  Optional  Indications.— This  group  is  relatively 
small,  containing  only  two  classes,  viz.: 

(0)  Quiet  eyes,  apparently  normal  in  every  way  save  that  they 
are  blind  from  total  leucoma  of  the  cornea. 

(b)  All  instances  of  bilateral  blindness  in  which  the  removal 
of  an  eye  or  the  eyes  would  decidedly  improve  the  personal 
appearance. 

Remarks.— This  group  is  so  named  because  it  embraces  those 
cases  concerning  which  it  is  purely  a  matter  of  choice  on  the  part 
of  the  patient  whether  or  not  he  parts  with  an  ugly  useless  member. 
Class  b  is  peculiar  in  that,  of  all  the  classes  under  the  three  groups, 
it  is  the  only  one  that  does  not  assume  some  degree  of  usefulness  on 
the  part  of  the  other  eye.  Like  Group  2,  there  can  hardly  be  a  doubt 
but  that  exenteration  is  the  preferable  procedure  whenever  practicable 
for  this  division  also.  It  may  be  mentioned  in  passing  that 
Class  a  of  this  group  includes  just  the  cases  that  are  appropriate 
for  tattooage  of  the  cornea. 

Concluding  Observations.  Age  of  Patient.— Neither  extreme 
—that  of  youth  nor  that  of  age— are  considered  bars  to  an  urgently 
needed  enucleation. 

Anesthesia. — Narcosis  is,  of  course,  the  rule,  and,  all  things  else 
being  ecpial,  is  most  suitable.  Excision  of  the  globe  has  frequently 
been  accomplished  under  local  anesthesia,  but  it  is  far  from  being  a 
pleasant  undertaking.  Seeing  that  the  really  painful  part  of  the 
operation  is  the  section  of  the  optic  and  ciliary  nerves,  it  is  quite 
possible  to  perform  this  step  under  chlorid  of  ethyl  or  even  nitrous 
oxid,  having  executed  all  those  preceding  under  cocain.  For 
subjects  who  are  unfit  for  ether  or  chloroform  this  method  is  highly 
to  be  recommended.  Indeed,  as  regards  the  youngest  class  of  sub- 
jects, it  is  practicable  to  make  the  entire  operation  under  the  ethyl 
chlorid.  Highly  inflamed  and  sensitive  eyes  do  not  admit  of  using 
local  anesthesia  at  any  stage  of  the  ])roccdure. 


CHAPTER  XL 
EXTRACTION  OF  CATARACT. 

GENERAL    CONSIDERATIONS. 

•  Condition  of  Patient's  General  Health. — All  that  is  requisite  in 
this  particular  is  that  the  patient  be  in  his  usual  health  and  that  this 
should  be  such  as  to  give  a  reasonable  expectation  of  life.  While 
it  is  well,  as  a  routine  practice,  to  make  careful  physical  examination, 
there  are  really  very  few  pathological  conditions  existing  in  cataract 
subjects,  as  we  find  them,  that  are  actual  contraindications  as  regards 
the  operation  of  extraction.  Although  it  is  almost  the  universal 
custom  (with  the  writer  among  the  rest)  to  ascertain  the  exact 
condition  of  the  urine;  neither  diabetes  nor  nephritis  are  actual  bars 
to  the  operation  so  long  as  dissolution  is  not  imminent.  The  same 
may  be  said  of  cardiac  disease,  aortic  insufficiency,  etc.  General 
arteriosclerosis,  while  it  makes  one  fear  expulsive  hemorrhage 
from  the  choroid,  should  not  cause  rejection,  but  should  lead  to 
extreme  caution  and  to  the  institution  of  appropriate  preparatory 
measures  as  regards  diet  and  other  regimen;  also  the  exhibition  of 
remedies  whose  effects  are  supposed  to  counteract  the  evils  of  this 
disease. 

Age  of  the  Subject. — Extreme  old  age  of  itself  should  not  stand 
in  the  way.  The  writer's  eldest  subject  was  ninety-two,  and  the 
result  was  all  that  could  be  desired.  On  the  other  hand,  given  an 
unusually  youthful  subject  for  senile  cataract,  the  question  merely 
hinges  upon  the  kind  of  cataract  and  the  manner  of  operating  to  be 
undertaken. 

Condition  of  the  Eye  and  its  Appendages. — There  should  be 
no  thought  of  operating  for  cataract  upon  an  eye  so  long  as  there  is 
any  active  inflammatory  condition  of  either  the  globe  or  its  ap- 
pendages, such  as  conjunctivitis,  acute  catarrhal  disease  of  the 
lacrimal  canal,  and,  above  all,  dacryo-cystoblennorrhea.  These, 
when  present,  even  in  the  opposite  eye,  should  first  be  got  rid  of. 
It  is  not  to  be  expected  that  there  should  actually  be  a  normal 
32  497 


498  EXTRACTION  OF  CATARACT 

lacrimal  passage — even  mucocele  docs  not  deter  some  good  men. 
Old,  burnt  out  stages  of  trachoma,  provided  there  is  not  entropion, 
with  trichiasis,  etc.,  may  be  ignored.  Bacteriologic  investigation 
of  the  apparently  healthy  conjunctiva  preliminary  to  extraction 
might  seem  to  be  unnecessary,  yet  it  is  really  important  as  it  oc- 
casionally reveals  an  incipient  infection  that  would  positively  pro- 
hibit the  operation  for  the  time. 

Suppuration  of  the  lacrimal  canal,  when  very  slight,  is  best 
dealt  with  either  by  searing— thus  sealing — the  puncta  with  the 
galvano-cautery  or  by  ligation  of  the  canal  with  a  single  thread,  just 
at  the  union  of  the  two  canaliculi,  immediately  preceding  the  extrac- 
tion; i.e.,  when  the  patient  is  on  the  table  for  the  latter.  With  the 
more  profuse  and  chronic  forms,  however,  it  is  best  not  to  temporize, 
but  at  once  to  extirpate  the  sac  and  as  much  as  its  practicable  of  the 
canaliculi.  (See  "Operations  upon  the  Lacrimal  Apparatus.") 
Pterygium,  progressive  or  encroaching  upon  the  pupil  should  first 
be  removed  while  an  old,  stationary  one,  not  affecting  the  pupillary 
area,  is  best  let  alone.  The  skin  of  the  lids  should  be  fairly  free 
from  disease. 

Condition  of  the  Globe. — First  and  foremost,  there  must  be 
tolerable  light  perception,  if  not  projection.  One  must  judge  of  the 
individual  case.  Black  cataracts  and  those  with  very  thick  or 
calcific  anterior  capsules  may  very  greatly  interfere  with  these 
functions,  even  though  the  deeper  structures  be  normal.  On  the 
other  hand,  many  eyes  characterized  by  chronic  or  very  old  choroidal 
and  retinal  lesions  and  affections  may  give  most  gratifying  results 
after  extraction. 

The  Cornea. — Opacity  of  this  membrane,  so  long  as  it  alone  does 
not  preclude  the  possibility  of  useful  sight,  should  not  prohibit 
extraction.  Arcus  senilis  presents  no  special  obstacles  to  the  heal- 
ing process,  though  it  is  likely  to  cause  "grooving"  of  the  wound 
made  for  extraction.  The  cornea  should  be  examined  with  the 
ophthahnometer  Ix'fore  operation  so  as  to  detect  any  astigmatism, 
regular  or  irregular,  that  would  interfere  materially  with  the  vision 
after  the  extraction. 

The  Iris  and  Pupil. — Only  some  active  pathological  process  of 
the  iris  would  Ix-  cause  for  non-interference.  It  is  highly  desirable  to 
have  a  normal  iris  and  a  ])upil  that  reacts  well  to  light,  yet  if  dealt 
with  as  the  exigencies  of  the  case  demand,  one  need  not  hesitate  to 
o|)erate  e\en  when  ihcrr  is  a  \ery  great  (lej)arturc  from  the  normal. 


rOXDITIOX    OF    THE    LENS  4Qg 

One  of  llic  author's  mosl  salisfyint^'  cases  is  llial  of  a  woman,  blind 
in  both  eyes  from  anterior  uveitis,  exclusion  and  occlusion  of  pupils, 
opacity  of  the  lenses,  and  even  opacity  of  the  lower  halves  of  the 
corneas — the  result  of  punctate  keratitis  which  afterward  extended 
to  the  whole  thickness.  Ten  years  ago  I  made  in  this  case  upward 
iridectomies,  then  extractions  ,and,  lastly,  discissions,  and  the  ])atient 
has  good  vision  in  both  eyes  to-day — even  reads  and  sews  without 
difficulty. 

Condition  of  the  Lens  Itself. —  It  is  highly  to  be  recommenfled 
that,  as  nearly  as  possible,  the  exact  character  of  the  cataract  be 
ascertained,  for  on  this  often  depends  the  surgical  methods  we  are 
to  pursue  in  dealing  with  it.  If  there  is  much  clear,  soft  cortex 
an  iridectomy  is  indicated,  or  if  the  anterior  chamber  be  very 
shallow  and  the  opacity  be  an  even  gray — not  white — throughout, 
we  may  suspect  a  large  sclerosed  cataract  which  will  necessitate  a 
large  corneal  section.  As  to  this  point  we  are  usually  put  in  the 
position  where  we  have  but  little  to  choose;  as,  aside  from  the  fact 
that  a  certain  number  of  cases  on  first  presentation  are  those  of 
incipient  cataract,  the  great  majority,  particularly  in  hospital 
practice,  have  already  reached  or  passed  the  requisite  stage  of 
ripeness.  The  circumstances  under  wdiich  the  patient  comes  to  us 
make  it  often  the  choice  of  two  evils — to  operate  on  an  unripe 
cataract  or  to  send  him  many  miles  to  his  home.  Again,  the  \ery 
form  of  cataract  that  we  prefer  to  let  alone  till  mature,  viz.,  the 
so-called  nuclear,  with  transparent  cortex,  is  precisely  the  kind  that 
causes  greatest  blindness  w^hen  in  this  unready  state.  Preliminary 
iridectomy  is  almost  a  necessity  before 'the  extraction  of  all  highly 
immature  cataracts. 

In  a  large  charitable  institution  like  the  Illinois  Eye  and  Ear 
Infirmary,  for  example,  where  indigent  cataract  patients  are  sent  to 
us,  at  the  public  expense,  from  remote  parts  of  the  State,  we  o])erate 
on  many  a  cataract  that  in  private  practice,  or  belonging  to  anyone 
residing  at  convenient  distance,  would  be  allowed  to  grow  more 
opaque.  Yet,  on  the  whole,  considering  the  class  of  patients  we 
have  to  deal  with,  I  think  the  results  we  obtain  in  this  hospital  will 
compare  favorably  with  any. 

It  is  not  wise,  on  general  principles,  to  extract  the  lens  from 
an  eye  possessed  of  vision,  for  example,  exceeding  one-fortieth  of 
the  normal,  yet  with  double  cataract  and  no  better  vision  in  either 
eye,  even  such  a  restriction  seems  too  great,  in  view  of  the  i)robable 


500  EXTRACTION  OF  CATARACT 

results  under  modern  methods.  The  mere  fact  that  a  senile  lens 
is  even  fairly  transparent  does  not  of  necessity  indicate  that  it 
is  not  entirely  operable,  i.e.,  capable  of  being  extracted  intact.  This 
is  the  case  with  the  large  sclerosed  lenses.  Indeed,  it  is  not  so  much 
the  so-called  immature  cataracts  that  expose  to  the  graver  dangers, 
but  the  complicated,  anomalous,  and  degenerated  ones.  When 
the  patient's  only  hope  of  continued  sight  is  centered  in  one  eye, 
then  I  should  say  do  not  operate  so  long  as  there  is  useful  vision. 
If  the  fellow  eye  be  sound,  especially  if  its  lens  also  is  cataractous, 
greater  liberty  is  allowable.  Moreover,  it  is  perfectly  justifiable, 
nay,  advisable,  to  remove  a  cataract  from  an  eye  whose  fellow  is 
normal,  provided  the  stage  of  opacity  is  fit  and  the  conditions  in 
general  are  favorable.  It  is  the  duty  of  every  individual  to  obtain 
what  sight  is  possible  in  both  eyes  in  order  to  have  a  wholesome 
reserve  in  the  event  of  an  emergency.  True,  the  immediate  result 
is  not  so  gratifying,  either  to  the  patient  or  to  the  operator,  be  the 
operation  ever  so  successful,  as  the  former  cannot  appreciate  the 
added  vision,  especially  when,  as  it  sometimes  happens,  an  annoying 
diplopia  ensues.  Later  this  will  disappear,  whereas,  if  left  alone 
the  cataract  would  reach  a  stage  not  so  favorable  for  extraction. 
It  is  also  an  error  to  assume  that  binocular  single  vision  is  impossible 
in  such  cases. 

To  operate  for  cataract  upon  both  eyes  at  one  sitting  would, 
according  to  most  surgeons,  the  writer  included,  be  the  height  of 
folly  unless  the  circumstances  were  peculiar.  If  some  unknown 
or  unforeseen  danger  threatened,  it  would  likely  be  common  to  both 
eyes.  Then,  too,  through  the  experience  gained  by  operation 
upon  one  eye — as  to  the  patient's  behavior  and  as  to  any  unpleasant 
physical  happenings  during  and  after  the  extraction — one  would 
be  in  better  position — would  know  his  ground,  so  to  speak — when 
it  came  to  dealing  with  the  other  eye.  True,  there  are  some  strong 
arguments  advanced  in  favor  of  greater  boldness  in  this  regard. 
As,  for  example,  through  timidity  the  patient  might  refuse  extraction 
on  the  second  eye  and  thus  be  deprived  of  the  benefits  of  bilateral 
vision.  Again,  a  double  extraction  means  practically  one  operation, 
and  one  course  of  after-treatment,  which  has  great  weight  in  our 
consideration  for  the  comfort  and  convenience  of  these  elderly 
and  feeble  subjects,  particularly  when  they  live  some  distance  away. 
A  recent  paper  by  Howard  Hansell,  of  Philadelphia,  in  favor  of 
double  extraction  of  senile  cataract,  and  the  discussion  thereon  was 


PREPARATION    OF    THE    PATIENT  5OI 

published  in  the  January  (1904)  nunil)cr  of  the  0/;/////(//w/r  Record, 
Chicasj;o. 

The  Preparation  of  the  Patient. — Let  it  ])e  understood  the 
followin<r  precautions  hold  j^ood  for  most  of  the  eye  operations  that 
are  practiced,  whether  on  lids  or  globe. 

Whenever  possible,  the  operation  should  be  made  in  a  well- 
regulated  hospital.  The  conditions  for  success  are  neither  pro- 
pitious nor  convenient  even  in  the  best  appointed  homes.  The 
patient  should  be  admitted  to  the  institution  at  least  twenty-four 
to  forty-eight  hours  previously  in  order  to  give  time  for  preliminaries. 
A  bath  is  usually  in  order,  though  as  regards  a  certain  proportion 
of  these  elderly  individuals,  we  should  hesitate  before  actually 
putting  them  into  the  tub.  Ordinarily  cleanliness  from  head  to 
foot,  however,  must  be  insisted  upon. 

It  is  necessary,  too,  that  the  bowels  and  the  urinary  organs  be 
in  a  normal  state;  indeed,  a  good  routine  practice  is  to  administer 
a  cathartic,  with  calomel,  the  first  evening  at  the  hospital,  followed 
by  a  saline  draught  the  next  morning.  The  diet  should  be  as 
light  as  is  consistent  with  health  throughout  the  treatment.  It 
goes  without  saying  that  at  this  time  a  careful  examination  should 
be  made  of  the  eyes  and  the  results  fully  recorded.  Examine  for 
signs  of  arteriosclerosis  and,  if  present,  institute  the  regimen  that 
is  calculated  to  put  such  a  subject  in  favorable  condition  for  the 
operation.  Light  diet,  an  abundance  of  pure  water,  aperients,  and, 
possibly,  the  exhibition  of  such  medicaments  as  are  supposed  to 
reduce  blood  pressure.  The  surgeon  in  charge  should  be  apprized 
of  the  findings  so  that  he  may  be  on  his  guard.  (See  chapter  on 
Para-operative  Technic.) 

Incidentally,  a  little  beforehand  training  of  the  patient  in  the 
different  acts  he  is  expected  to  perform  during  the  operation  would 
be  well-timed,  as  it  tends  to  confidence  both  on  his  and  the  surgeon's 
part.  Placing  him  in  a  chair,  instilling  boric  acid  solution  into  the 
eye,  manipulating  the  lids,  having  him  rotate  the  eyes  in  different 
directions,  opening  and  shutting  them,  etc.,  and  all  without  telling 
him  why  these  things  are  done.  It  is  the  practice  of  some  surgeons 
to  apply  a  test  bandage  to  the  eye  that  is  to  be  operated,  leaving  it 
over  night,  with  the  view  to  ascertaining  whether  any  undue  secre- 
tion from  the  conjunctiva  occurs.  This  procedure  I  consider  not 
only  unnecessary,  but  positively  injudicious,  since  the  mere 
occlusion    of   the   eve    actually   tends   to   an    abnormal    secretion 


502  EXTRACTION  OF  CATARACT 

through  retention  and  consequent  prohferation  of  bacteria  normally 
present. 

At  the  time  appointed  for  the  extraction,  the  patient  is  washed, 
combed,  clad  in  a  nightdress,  over  which  is  worn  a  heavier  garment 
(sterilized),  such  as  a  bathrobe,  and  the  feet  are  encased  in  warm, 
sterilized  hospital  sli])pcrs. 

Preparation  of  the  Eye. — As  stated  elsewhere,  it  is  the  writer's 
custom  to  instill  a  drop  of  atropin  solution  into  the  eye  about  one 
hour  previous  to  the  operation.  After  one  hour  the  relaxation  of 
the  iris  is  pronounced  enough,  in  the  average  case,  to  bring  about 
the  desired  results.  The  indiscriminate  or  prolonged  use  of  mydri- 
atics in  the  eyes  of  elderly  individuals  is  not  without  its  risks,  chief 
among  which  is  hypertension  of  the  globe,  with  its  train  of  troubles. 
Then  the  general  toxic  effect  is  thought  to  increase  the  Hability  of 
postoperative  delirium.  Having  applied  the  one  drop  to  the  eye, 
no  more  is  instilled  unless  something  in  the  after-treatment  calls 
for  it.  The  mydriasis,  which  disappears  with  the  escape  of 
the  aqueous,  reasserts  itself,  but  in  a  feeble  manner,  after  the 
healing  of  the  incision.  It  matters  not  whether  the  simple  or  the 
combined  method  of  extraction  is  contemplated,  the  mydriasis 
favors  either  expulsion  of  the  lens,  or  the  withdrawing  of  the  iris  for 
iridectomy. 

For  the  I'lrst  examination  of  the  eye,  we  often  wish  to  use  a  mydri- 
atic to  satisfy  ourselves  as  to  how  far  the  pupil  is  dilatable  and  as  to 
the  appearance  of  the  peripheral  portions  of  the  cataract,  for  which 
purposes  cocain,  perhaps,  is  the  best,  as  its  effect  is  transient,  and 
it  has  not  the  tendency  to  excite  overtension  possessed  by  most 
other  mydriatics.  It  has  been  argued  that  mydriasis  leads  to  ex- 
trusion and  entanglement  of  the  iris  at  the  incision.  I  take  the 
ground  that  there  is  no  such  involvement  excepting  when  the 
anterior  chamber  is  empty  or  in  the  act  of  emptying,  at  which 
times  the  mydriasis  cannot  be  a  factor,  as  it  is  then  practically 
absent. 

Immediately  before  putting  the  patient  on  the  table  the  eye  is 
given  its  fmal  cleansing,  which  consists  of 

1.  The  requisite  manipulation  and  massage  of  the  lids  for  the 
expression  of  the  contents  of  the  Meibomian  ducts. 

2.  The  washing  or  scrubbing  of  the  entire  face,  up  to  the  hair 
and  down  to  the  neck,  giving  special  attention  to  the  cilia  and  lids, 
with  slerile  green  soap  and  hot  sterilized  water.     If  the  supercilia 


PREPARATION    OF    THE    PATIENT  503 

are  long  and  thick,  they  are  shaved;  if  not,  merely  lathered  and 
scrubbed.  It  would  seem  an  act  of  supererogation  to  make  a  rule 
of  shaving  the  eyebrows  when  the  lashes,  be  they  ever  so  numerous 
and  lengthy,  are  left  intact.  But  to  trim  off  the  cilia,  save  those  of 
the  upper  lid  near  the  outer  canthus,  were  a  grave  mistake,  as  the 
stubs  of  hairs  would  be  a  source  of  considerable  irritation.  To 
wash,  or  rather  to  thoroughly  dampen  the  cilia  with  benzin  is  a 
most  excellent  preparatory  measure,  as  the  residue  left  on  the  hairs 
after  the  evaporation  of  the  liquid  makes  an  effective  coating  in 
which  the  bacteria  are  imprisoned. 

3.  The  patient  is  put  into  a  half-reclining  position  and  the  eye 
copiously  irrigated  with  lukewarm  boric  acid  solution,  the  lids  being 
everted  during  a  part  of  the  time.  Throughout  all  of  these  prep- 
arations, great  care  should  be  exercised  to  avoid  undue  violence. 
A  jab  of  the  thumb,  knuckle,  or  scrub-brush  could,  in  the  eye  of 
these  senile  subjects,  lead  to  very  unpleasant  results;  and  in  the  use 
of  the  cotton  sponges,  or  other  implements,  one  must  never  touch 
the  cornea,  as  the  consec^uent  removal  of  a  patch  of  epithelium 
leaves  a  spot  especially  vulnerable  to  bacteria. 

4.  A  thin  sheet  of  absorbent  cotton,  wet  with  boric  acid  solution, 
is  spread  upon  the  closed  lids  on  which  is  laid  a  pad  of  dry  cotton. 
Dry  cotton  is  never  put  next  the  eye  in  a  dressing  nor  used  to  wipe 
the  lids,  because  of  the  loose  fibres  entering  the  conjunctival 
sac.  Over  all,  tied  obliquely  around  the  head,  is  applied  a  two 
and  one-half  inch  wide  strip  of  sterilized  muslin,  or  netting,  and 
in  this  dress  the  eye  awaits  the  moment  when  the  operation  is  to 
begin. 

When  the  patient  is  brought  to  the  operating-table  (and  it  is  better 
that  he  be  led,  rather  than  carried  or  wheeled)  a  strong  box  or 
step  is  placed  for  him  by  which  to  mount.  He  is  told  to  first  sit 
upon  the  table  at  its  middle,  then  to  lie  down,  when  the  top  of  the 
head  is  placed  even  with  the  head  of  the  table-top,  lying  on  a  thin, 
firm  pillow. 

While  instructing  the  patient  during  this  performance  of  placing 
him  upon  the  table,  as  indeed  on  all  occasions,  it  should  be  done  in 
the  gentlest,  quietest,  and  most  adroit  manner,  so  as  not  to  fluster 
him.  We  have  too  often  seen  these  unfortunates  victimized  by 
brutal  or  thoughtless  attendants,  yea,  by  the  surgeon  himself,  and 
as  often  observed  the  demoralizing  effect.  Storming,  gesticulating, 
jerking,  thumping,  and  even  swearing  at  the  patient  seem  to  have 


504 


EXTRACTION    OF    CATARACT 


their  uses  among  our  confreres  of  certain  nationalities,  judging 
from  the  frequency  of  their  use;  but  I  much  doubt  their  wisdom  in 
any  country,  most  of  all  in  our  own,  especially  with  our  own  people. 
They  serve  merely,  in  most  instances,  to  rob  the  patient  of  whatever 
coolness  he  is  possessed  withal,  and  to  lead  to  disagreeable  com- 
plications, if  not  to  disastrous  consequences. 

The  entire  body,  up  to  the  head,  is  covered  with  a  sterile  sheet. 
Sterile  towels  are  placed  around  the  neck,  over  pillows  and  (a  light 
one)  over  the  mouth  and  nose.     A  linen  cap,  with  drawstring,  or  a 


Fig.  281. — Position  facing  patient.     Right  eye.     Left  hand  making  section. 
The  knife  is  pushed. 

rubber  cap,  is  put  upon  the  head,  covering  all  the  hair,  and  the 
siring  securely  tied. 

The  Anesthesia. — I  shall  ever  guard  the  pleasant  remembrance 
of  the  wonder  and  gratitude  excited  in  the  medical  world  by  Koller's 
rc])ort  upon  the  local  action  of  cocain  in  the  autumn  of  1883.  I 
was  then  a  student  of  ophthalmology  in  New  York,  and  it  was,  of 
course,  particularly  the  impression  made  upon  the  minds  of  the 
votaries  of  this  branch  of  medicine  to  whom  local  anesthesia  has 
proven  the  greatest  boon  that  I  refer.  Notwithstanding  the 
many  other  drugs  similar  in  tlicir  action  that  have  been  brought 
forward,  several  of  which  1  have  tried,  cocain  is  to-day,  in  my 
opinion,  the  most  elTicient  and  desirable. 

Cocainization. — Three  or,  at  most,  four  drops  of  properly  and 
freshly  prcjjared  4%  solution  of  cocain  hydrobromate,  instilled  with 


THE    SIMPLE    METHOD 


two-minute  intervals,  should  be  sufl'icicnt  for  the  thorou^ii  anesthesia 
of  the  eye.  It  will  be  borne  in  mind  that  too  much  cocain  or  the 
too  prolonged  use  of  it  tends  to  hypotonicity  of  the  globe,  to  corneal 
collaj)se,  to  hemorrhage,  and  to  exfoliation  of  the  corneal  epithelium. 
Between  drops,  and  throughout  the  entire  operation,  when  nothing 
is  being  done  to  the  eye,  it  should  be  kept  closed,  and  the  lids 
covered  with  a  pad  of  cotton  wet  with  warm  boric-acid  solution. 


Fig.  282. 


Manner  of  making  corneal  section  with  right  hand  while  facing  patient. 


SIMPLE    PERIPHERAL  CORNEAL    FLAP   EXTRACTION. 

DESCRIPTION     OF     THE    OPERATION    OF     EXTR.ACTION    AS     PRACTICED 
BY    THE    AUTHOR. 

The  surgeon,  the  patient,  and  the  requisite  apparatus  having 
been  duly  prepared  (see  chapter  on  "Preparation  of  Patient"),  the 
operator  takes  his  place  at  the  head  of  the  table,  his  assistant,  who 
has  charge  of  the  instruments  and  other  needed  articles,  being  at 
his  left,  and  the  assistant  operator  at  his  right. 

If  the  operator  is  ambidextrous,  he  stands  at  the  head  of  the 
table,  of  course,  for  either  the  right  or  the  left  eye.  Should  he  be 
at  all  in  doubt,  however,  as  to  his  ability  to  make  a  satisfactory 
section  with  his  left  hand,  he  should  have  no  hesitancy  in  standing 


5o6  EXTRACTION  OF  CATARACT 

with  his  left  side  to  the  table,  for  the  left  eye,  so  as  to  make  the 
section  with  his  right  hand.  There  is  nothing  derogatory  in  thus 
acknowledging  his  slight  limitation.  Indeed,  there  is  much  to  be 
said  in  favor  of  the  position  at  the  side  or  facing  the  patient.  (See 
page  113). 

A  few  words  of  reassurance  and  instruction  are  spoken  to  the 
patient,  such,  for  instance,  as,  "I  shall  not  hurt  you,  be  quiet  and 
do  not  squeeze  the  lids,"  and  the  blepharostat  is  introduced.  We  will 
suppose  it  is  the  right  eye  which  is  in  question,  and  the  table 
has  been  set  diagonally  to  the  window  as  stated.  The  Beard 
modification  of  Mellinger's  speculum  is  employed.  To  put  this 
instrument  in  place  the  handles  are  grasped  by  the  thumb  and  two 
fingers  of  the  right  hand  and  pressed  as  near  together  as  they  will 
go,  while,  with  the  thumb  and  middle  finger  of  the  left  hand,  the 
lids  are  pushed  widely  apart,  the  patient  meanwhile  looking  straight 
ahead,  and  the  lid-holders  are  gently  and  deftly  slid  into  place- 
first  the  upper,  then  the  lower — and  allowed  to  separate  by  pressure 
of  the  spring  alone.  If  the  lids  do  not  open  suflficiently,  ask  the 
patient  to  relax  the  lids  and,  at  the  same  time,  slowly  press  upon  the 
ends  of  the  slides,  thus  forcing  the  lids  apart.  Cut  off  the  lashes 
of  the  upper  lid  exterior  to  the  lid-holder  if  in  the  way.  This  is 
best  done  with  small  straight  scissors,  meanwhile  holding  a  thin  pad 
of  wet  cotton  so  as  to  protect  the  eye  from  the  falling  hairs.  From 
an  eye-dropper  or  other  suitable  implement  a  quantity  of  warm 
boric  solution  is  poured  on  to  the  cornea  and  neighboring  con- 
junctiva (the  operator  will  find  it  of  advantage  to  warn  the  patient 
when  about  to  pour  or  drop  liquid  into  or  upon  the  eye,  as  to  do  so 
unexpectedly  is  apt  to  cause  a  start  or  a  wince),  after  which  that 
portion  of  the  licjuid  caught  behind  the  lower  lid  is  imbibed  by  a 
cotton  sponge. 

The  assistant  operator  places  his  left  hand  on  the  patient's  brow 
and  supports  it  with  his  thumb  pressed  firmly  on  the  upper  rim 
of  the  orbit,  droj)])ing  his  wrist  and  forearm  well  down  so  as  to  get 
them  out  of  the  way  of  the  operator.  This  grip  on  the  brow  dis- 
courages a  spasm  of  the  orbicularis,  aside  from  forcibly  preventing  it. 

Fixation  of  the  Globe. — The  surgeon  takes  the  knife  in  his  right 
hand  (f(jr  the  right  eye),  the  forceps  in  his  left.  The  best  point  at 
which  to  take  hold  wilh  the  fixation  forceps  in  upward  extraction  is 
a  matter  of  no  mean  im])()rtance.  The  ])oint  in  question  is  at  or 
near  the  center  of  llie  inferonasal  fourlli  of  tlie  corneal  limbus;  in 


PUNCTURE  507 

Other  words,  just  beneath  the  inner  extremity  of  the  horizontal 
diameter  of  the  cornea.  To  grasjj  the  tissues  here  affords  a  much 
more  satisfactory  means  of  controUin<,r  the  eyeball  than  does  the 
more  generally  chosen  one  of  seizing  them  in  the  vertical  meridian 
below  the  cornea.  It  is  especially  effective  in  preventing  torsion  of 
the  globe  during  the  keratotomy.  The  jaws  of  the  forceps  are 
placed  against  the  eye  closed,  then  allowed  to  open.  Thus  the  loose 
structures  are  smoothed  out  or  put  lightly  on  the  stretch,  the  object 
being  to  obviate  picking  up  too  much  of  the  conjunctiva,  thereby 
causing  it  to  overlap  the  cornea  along  the  site  of  the  proposed  in- 
cision. The  instrument  is  then  pressed  more  firmly,  and  a  good 
big  bite  is  taken,  and  as  deep  a  one  as  can  be  obtained.  The  fold 
composing  this  bite  should  stand  perpendicular  to  the  tangent  of 
the  limbus.  If  the  conjunctiva  proves  too  friable  to  insure  a 
sufficient  hold,  try  lower  down  or  even  beneath  the  cornea.  The 
forceps  referred  to  here  are  without  a  catch  or  lock  and  have  broad 
jaws.  If,  while  the  knife  is  engaged  in  the  section,  the  fixation 
becomes  insecure  because  of  a  purely  conjunctival  bite,  twisting 
of  the  forceps  on  its  long  axis  will  tighten  the  hold.  The  second 
finger  rests  upon  the  patient's  nose,  the  third  and  fourth  upon  the 
opposite  cheek,  and  the  hold  is  steadily  maintained,  meanwhile 
scrupulously  avoiding  either  to  press  or  to  pull  upon  the  eyeball. 
Now,  a  look  is  given  at  the  knife  to  see  that  its  edge  is  directed  ufnvard, 
and  the  incision  is  begun. 

Puncture.— The  point  is  placed  exactly  at  the  apparent  sclero- 
corneal  junction,  just  on  a  level  with  the  union  of  the  middle  and 
upper  thirds  of  the  vertical  diameter  of  the  corneal  base.  Puncture 
and  counterpuncture  may  be  a  trifle  lower,  of  course,  but  it  is  hardly 
wise  to  begin  higher.  Rest  the  little  finger  on  the  patient's  cheek, 
and  have  him  look  down— not  a  bad  idea  to  direct  him  also  to  hold 
the  mouth  and  the  other  eye  wide  open.  The  handle  of  the  knife 
is  elevated  to  about  45°  to  a  tangent  of  the  corneal  curve,  and 
pushed  until,  just  as  it  is  entering  the  anterior  chamber,  tlie  handle 
is  depressed,  in  one  sense,  till  the  blade  is  brought  parallel  with  the 
plane  of  the  corneal  base,  and  elevated,  in  another  sense,  so  as  to 
point  toward  the  center  of  the  pupil,  advancing  all  the  while;  then 
again  depressed  (toward  the  patient's  feet)  and  made  to  emerge 
from  the  anterior  chamber  precisely  opposite  to  the  point  of  entrance 
{counterpuncture)  (Fig.  283).  Now,  onward,  vigorously,  without 
hesitation,  first  pushing  up  the  blade  to  make  the  cut  on  the  inner 


5o8 


EXTRACTION    OF    CATARACT 


side  of  the  cornea,  then  pulling  it  up  to  cut  the  outer  side,  holding  it 
flat  on  the  iris,  and  following  the  apparent  sclerocorneal  junction — 
rather  rocking  than  sawing — till,when  the  edge  has  just  reached  the 
upper  angle  of  the  iris,  it  is  given  about  one-eighth  of  a  turn  back- 
ward, and  made  to  emerge  beneath  the  conjunctiva,  so  as  to  make  a 
small  conjunctival  flap  (Fig.  284).  The  length  of  this  flap  should 
be  about  three  or  four  millimeters,  and  the  width  four  or  five  milli- 


FiG.  283. — Puncture  and  counter-puncture. 


meters.  When  sufiicient  of  the  conjunctiva  has  been  lifted  u]),  the 
edge  of  the  knife  is  suddenly  turned  directly  forward  and  the  flap 
cut  off.  The  fixation  forceps  is  now  removed  and  the  operator, 
himself,  may  support  the  brow.  Before  going  further  the  con- 
junctival flap  is  turned  down  over  the  cornea,  else  it  may  give 
trouble  later  by  getting  into  the  incision.  This  is  best  done  with 
the  back  of  the  ready-to-be-discarded  knife  and  not  with  any 
instrument  that  has  yet  to  enter  the  globe. 

In  completing  the  corneal  section,  it  is  best  to  slow  up  somewhat 
so  as  to  cut  out  without  a  sudden  jerk,  as  this  might  have  the  ctTcct 
of  producing  a  prolapse  of  the  iris  or  of  causing  an  involuntary 
movement  on  the  part  of  the  patient,  such  as  a  spasm  of  the  orbic- 
ularis.    Indeed,  the  only  period   in   ihe  making  of  the  section  that 


THE    CYSTOTOMY 


509 


should  be  as  brief  as  possible  is  that  between  the  instant  of  counter- 
puncture  and  the  moment  when  the  edge  of  the  knife  has  just  passed 
beyond  the  upper  border  of  the  pupil.  A  certain  rapidity  of  exe- 
cution here  insures  against  catching  the  iris  upon  the  knife.  Take 
care  not  to  prick  the  lid  or  the  nose  with  the  point  of  the  knife,  as 
it  causes  the  patient  to  start  and  squeeze  and  also  soils  the  knife.  In 
addition  to  supporting  the  brow,  particularly  with  nervous  or 
agitated  patients,  a  useful  precaution  is  to  have  a  trained  assistant 


Fig.  284. — Finishing  the  corneal  section  and  fashioning  the  conjunctival  flaj) 


•elevate  the  lid  holders  of  the  blepharostat  so  that  they  will  not  lie 
on  the  globe. 

Every  now  and  then  a  word  of  encouragement  spoken  to  the 
patient,  as  "all  is  going  well,"  "soon  over  now,"  and  never  failing 
to  express  commendation  of  good  behavior,  are  things  well  to 
remember. 

The  Cystotomy  or  Capsulotomy. — The  cystotome  is  held  pre- 
cisely as  in  the  accompanying  illustration  and  in  a  perfectly  horizontal 
position  (Fig.  285).  The  heel  of  the  instrument  is  slid  gently 
Ijeneath  the  conjunctival  flap,  thence  down  over  the  iris  until  it  is 
just  within  the  upper  portion  of  the  pupil;  then  pushed  behind  the 
iris  at  the  nasal  side,  holding  the  blade  flat  and  the  point  or  edge 
upward  all  the  while.  Now  the  handle  is  given  a  onc-quartcr  turn 
toward    the  operator,  so  as  to  bring  the  point  squarely  in  contact 


5IO  EXTRACTION  OF  CATARACT 

with  the  capsule  and,  pressing  hghtly  and  sHghtly  elevating  the 
handle,  an  incision  is  made,  in  a  light  curve,  almost  parallel  with 
the  equator  of  the  lens.  This  is  carried  as  far  to  the  outer  side 
as  was  its  beginning  to  the  nasal,  when  again  the  quarter  turn  is 
again  made  toward  the  operator,  to  bring  the  heel  upward,  and  the 
instrument  is  slid  out  at  the  incision,  heel  foremost. 

Delivery  of  the  Cataract. — The  back  of  the  Graefe  spoon  is 
placed  against  the  globe,  well  down  in  the  lower  fornix,  and  the  back 


Fig.  2S5. — The  cystotomy.     The  shank  of  the  cystotome   shoulc 
order  to  turn  without  wabbling. 


straight 


of  llie  Hat  s])()()n  is  laid  on  just  behind  the  incision  abo\e;  the 
patient  is  told  to  look  constantly  downward  (Fig.  28()).  (Some 
operators  have  a  light  held  low  down  for  the  subject  to  fix  his  eyes 
upon.)  Tlic  lower  spoon  is  pressed  lirmly  and  steadily,  but  not  too 
forcibly,  toward  the  center  of  the  globe,  while  with  the  upper  one  the 
posterior  lip  of  llie  incision  is  depressed,  kee])ing  botli  still,  i.e.,  not 


DKI.U'KRV    OF     rHK    I.KNS  S'' 

rubbing  them  back  and  forlli  nor  up  and  down.  Jl  is  a  curious  fact 
that  the  eye,  when  j)rofoundIy  cocainized  often  loses  its  sense  of 
orientation,  so  that  the  patient  cannot  with  certainty  give  it  the 
desired  direction,  hence  the  ad\anlage  of  giving  him  a  bright  object 
on  which  to  gaze. 

The  i'lrst  elTect  of  the  impact  of  the  spoons  is  to  cause  a  shght 
parting  of  the  Hps  of  the  incision,  Alayhap  the  advancing  lens  is 
covered  bv  the  iris;  if  so,  only  blackness  is  seen  in  the  opening. 


Fig.  286. — The  application  of  the  sjjoons  for  expression  of   the  lens 


This  must  be  ditTerentiated  from  another  sort  of  blackness,  viz., 
presentation  of  vitreous.  Pretty  soon  there  is  a  separation  of  the 
black  from  the  anterior  lip  of  the  cut,  and  the  edge  of  the  cataract 
rises  between.  Its  appearance  is  quite  characteristic — looking  gray, 
of  irregular  surface,  and  may  be  likened  to  a  bit  of  dirty  ice  that  has 


512  EXTRACTION  OF  CATARACT 

been  slightly  thawed.     It  should  be  borne  in  mind  that  a  too  rapid 
delivery  of  the  lens  is  harmful. 

The  cataract  having  presented  its  edge  in  the  incision,  it  gradually 
advances,  spoons  being  held  still  and  the  same  pressure  kept  up 
until,  when  the  widest  part  of  the  lens  is  just  passing  out  of  the 
incision,  the  lower  one  is  slid  upward,  the  patient  is  warned  not  to 
squeeze  when  a  bright  light  enters  the  eye,  and  the  lens  is  so  delivered 
as  to  cause  as  much  as  possible  of  any  following  cortex  to  come 
out  with  it  (Fig.  287).     This  is  accomplished  by  pausing  just  when 


Fig.  287.— Moment  in  the  delivery  of  a  cataract  when  the  cortex  should 
be  driven  up. 


the  greatest  diameter  of  the  lens  is  engaged  in  the  incision,  and 
driving  the  cortex  upward,  collecting  it  in  a  mass  about  the  lens,  by 
gently  stroking  the  cornea  with  the  back  of  the  spoon;  then,  with 
one  final  sweep,  delivering  nucleus  and  cortex  together.  Wilder,  of 
Chicago,  is  the  author  of  this  valuable  maneuver.  When  it  is 
clear  out,  if  there  is  thought  to  be  any  cortical  remains  left  behind, 
they  may  be  removed  as  follows: 

Removal  of  Cortex. — As  this  is  a  description  of  the  simj^le 
extraction,  it  is  assumed  that  the  cataract  is  of  a  kind  favorable 
to  the  operation.  Hence,  those  portions  that  are  stripped  off  in 
the  delivery  are  sup])()se(l  to  l)e  mainly  o])a(iuc — visible.     Moreover, 


KEMOVAL    OK    CORTKX  513 

the  appearance  of  the  cataract  tlial  has  been  remo\ed,  gives  an  idea 
as  to  about  how  much  of  it  may  ha\e  l)een  left  behind.  The  more 
complete  il  is  in  form,  the  less  the  residue.  The  consideration  of 
transparent  lens  remains  is  found  elsewhere  (see  page  557). 

The  blepharostat  may  be  taken  away,  the  lids  closed,  and  a  pad 
of  cotton,  wet  with  boric  acid  solution,  laid  on  them  for  a  few 
minutes,  while  a  certain  amount  of  aqueous  accumulates.  This  is 
supposed  to  favor  the  " milking"  out  of  the  lens  remains.  However, 
this  necessitates  either  replacing  the  speculum,  which  is  not  always 
a  safe  procedure  at  this  stage  of  the  operation,  or  using  the  retractor 
or  lingers  to  hold  back  the  upper  lid,  exposing  the  instruments  and 
incision  to  the  cilia  and  to  the  contents  of  the  Meibomian  canals. 
Besides,  the  pupil  would,  in  many  instances,  become  much  narrowed 
during  the  wait,  shutting  the  cortex  securely  in  the  posterior  cham- 
ber, thus  making  it  impossible  of  extraction.  For  these  reasons  the 
writer  prefers  to  go  ahead  at  once  without  removing  the  blepharostat. 

If  the  patient  is  of  the  irresponsible  kind,  the  assistant,  if  he  be 
clever,  might  steady  the  eye  with  the  fixation  forceps  during  this 
process,  but  I  have  for  a  long  time  proceeded  alone  in  all  cases, 
trusting  to  the  special  design  of  the  blepharostat  and  to  the  holding 
up  of  the  brow  to  prevent  loss  of  vitreous. 

The  site  of  the  incision  should  be  kept  bathed  with  boric  acid 
solution  and  the  spatula  and  spoon  wet  with  the  same.  If  the 
iris  has  been  displaced  during  the  delivery  of  the  cataract,  it  is  left 
so  until  after  the  cortex  is  disposed  of.  A  prolapsed  iris  rather 
favors  the  expulsion  of  lens  remains,  whereas,  should  there  be  a 
pause  just  prior  to  this  step,  the  iris  is  apt  to  go  back  spontaneously 
and  complicate  matters  by  shutting  off  the  cortex  from  the  anterior 
chamber.  The  brow  being  still  supported  either  by  the  assistant 
or  by  the  third  finger  of  the  surgeon's  left  hand,  the  ])atient  looking 
down,  the  assistant  still  holding  up  the  speculum,  the  spatula  (in 
the  left  hand)  is  entered,  vertically,  for  the  double  purpose  of  holding 
back  the  iris  and  affording  a  chute,  or  inverted  shoehorn  office; 
meanwhile,  from  without,  the  Graefe  spoon,  held  in  the  right  hand, 
is  used  to  follow  up  the  particles  by  a  very  gentle  patting  or  rubbing 
process  upon  the  cornea,  until  all  of  them  seem  to  have  been  removed. 
The  globe  must  be  closely  watched  during  this  procedure  so  that 
should  it,  as  it  often  does,  turn  suddenly  upward,  the  spatula  may 
be  as  quickly  withdrawn,  else  there  is  danger  of  its  puncturing  the 
posterior  capsule  or  ruj^turing  the  hyaloid  and  letting  out  the 
S3 


SH 


EXTRACTION    OF    CATARACT 


vitreous.  While  it  is  important  that  we  should  do  our  utmost  to 
that  end,  it  is  not  always  possible,  even  under  favorable  conditions, 
to  remove  all  the  opacity  from  the  pupil,  as  a  portion  of  the  posterior 
cortex  may  adhere  closely  to  its  capsule,  or  there  may  be  a  visible 
thickening  of  either  capsule,  and  it  is  not  wise  to  fuss  too  long  with 
that  which  shows  no  disposition  to  come  out.  This  will  often 
successfully  resist  efforts  at  removal  even  by  lavage. 


Fig.  288. — Intraocular  lavage.     Lippincott's  instrument. 


A  few  surgeons  still  employ  intraocular  irrigation,  or  lavage 
of  the  anterior  chamber  with  a  neutral  liquid  or  a  mild  antiseptic 
solution,  but  it  is  not  favored  by  the  great  majority  except  in  selected 
cases.  When  I  was  a  student  in  Paris,  I  became  favorably  im- 
pressed with  Ue  Wecker's  method  of  lavage,  and  bought  one  of  the 
syringes  he  devised  for  the  puri)ose,  but  have  never  employed  it  but 
once.  De  Wecker  afterward  abandoned  the  procedure.  At  the 
same  time,  Panas,  after  all  his  extractions  at  the  hos])ital  Hotel 
Dieii,  was  ])crf()rniing  a  species  of  lavage,  not  for  ihc  washing  out  of 


DON  TS  5  I  5 

cortical  remains,  but  as  a  means  of  preventing  sepsis.  There  ha\e 
been  a  number  of  irrigators  and  syringes  devised  for  washing  out  the 
anterior  chamber,  among  the  best  of  which  are  Lipj)incott's  (Fig. 
288)  and  McKeown's.  Lippincott  has  been  the  foremost  and  most 
constant  advocate  in  this  country  of  intraocular  lavage. 

Some  operators  counsel  entering  the  cannula  into  the  anterior 
chamber,  some  into  the  capsule  itself,  while  others  are  content  with 
merely  depressing  the  posterior  lip  with  it,  and  not  pushing  it 
beyond  the  inner  wound  opening.  The  reader  is  referred  to  a  paper 
by  Lippincott,  of  Pittsburgh,  in  the  American  Journal  of  Ophthal- 
mology for  July,  1904,  for  the  description  of  his  latest  irrigator, 
together  with  a  discussion  of  the  technic  and  indications  for  lavage. 
It  may  be  added  that  the  advocates  of  the  measure  advise  against 
prolonged  and  forcible  irrigation  and  against  the  use  of  any  but  the 
blandest  liquids  and  the  mildest  antiseptic  solutions,  such  as  sterile 
water,  normal  salt  solution,  etc.  Eserin  is  never  employed  after 
the  extraction  because  its  effect  favors  posterior  synechias  and 
iritis. 

don'ts. 

Rather  than  overburden  the  description  of  the  o])eration  with 
details,  the  latter  are  here  subjointed  as  don'ls. 

Don't  get  shaky.  Pick  up  the  knife,  make  a  few  Imger  move- 
ments with  it  and,  if  the  hand  is  turning  craven,  just  call  a  slight 
halt,  resort  to  a  Httle  inward  discipline,  and  one  can  usually  regain 
his  composure.  A  colleague  once  told  me  that  when  he  found 
himself  becoming  demoralized  on  the  eve  of  an  operation,  he  walked 
to  the  window  and,  while  apparently  taking  in  the  \\c\y,  proceeded 
to  give  himself,  mentally,  a  sound  castigation,  with  the  invariable 
eft'ect  of  restoring  his  calm. 

Don't  drop  cold  or  hot  liquid  into  the  eye  during  or  after  the 
operation — have  it  lukewarm.  Don't  let  it  fall  from  a  height  onto 
the  eye  and  lids,  as  all  tends  to  produce  wincing.  Don't  squirt  nor 
fire  solutions  at  the  eye,  but  pour  them  gently  over  it,  and  always 
warn  the  ])aticnt  of  your  intention.  Don't  |)ermil  sjionges  to  touch 
the  cornea  and  disturb  the  ej)ithelium. 

Don't  begin  the  instillation  of  the  cocain  solution  until  it  is  known 
that  the  operation  can  follow  in  not  more  than  ten  minutes.  Don't 
let  the  speculum  fly  out  of  the  lingers  like  a  Jack-in-the-box  while 
in  the  act  of  putting  it  in  position.     Get  a  good,  firm  grip  on  it. 


5l6  EXTRACTION  OF  CATARACT 

Don't  pry  the  lids  too  far  apart,  for  it  induces  spasm  of  the 
orbicularis  and  increases  intraocular  tension.  Don't  allow  the 
speculum  to  rest  heavily  upon  the  globe.  Don't  fail  to  lift  it  away 
from  the  eye,  and  with  a  lirm  grasp,  in  removal. 

Don't  use  fixation  forceps  that  have  a  catch,  and  don't  forget 
the  hand  that  holds  the  forceps,  while  fixing  the  eye.  Don't  rotate 
the  eye  with  the  forceps  as  if  it  rested  with  its  posterior  surface 
on  a  transverse  vertical  plane,  but  as  it  is,  like  a  ball  that  turns  on  a 
universal  central  pivot. 

Don't  seize  merely  a  fold  of  conjunctiva  by  which  to  steady  the 
eye,  but  in  addition,  as  much  as  possible  of  the  subjacent  tissues 
and  as  near  as  practicable  to  the  cornea.  Don't  employ  fixation 
after  the  bulbus  is  opened  unless  the  need  is  urgent. 

Don't  neglect  to  test  point  and  edge  of  both  knife  and  cystotome 
before  they  are  disinfected,  to  see  that  they  are  sharp.  Don't 
use  a  knife  with  long  needle-like  point — the  tip  might  break.  Don't 
hold  the  knife  so  tightly  as  to  cramp  the  fingers,  nor  yet  so  loosely 
as  to  cause  wavering.  Don't  attempt  either  corneal  or  capsule 
incision  free  hand.  No  matter  how  steady  the  latter,  always 
rest  the  little  finger  on  the  patient's  face  not  only  for  support,  but 
in  order  to  move  with  him  should  he  stir. 

Don't  haggle,  fuss,  nor  hesitate  in  making  the  section,  yet,  while 
forging  steadily  ahead,  do  so  with  a  certain  deliberateness.  Faulty 
sections,  premature  escape  of  aqueous,  etc.,  come  not  so  often  of 
slowness  as  of  vacillation. 

Don't  lose  sight  of  the  patient's  demeanor.  If  this  be  favorable 
throughout  the  corneal  section,  it  is  apt  to  be  so  for  the  entire  opera- 
tion. If  he  begins  to  squeeze,  pause,  even  though  "in  the  midst  of 
the  incision,  and  remonstrate  with  him  in  a  kindly  tone,  and  have 
the  assistant  guard  closely  the  brow  and  speculum. 

Don't  take  the  eyes  off  the  site  of  the  operation  for  an  instant. 
Have  the  assistants  so  trained  that  it  will  not  be  necessary  for  the 
operator  to  seek  instruments  and  implements,  nor  to  lay  them  down. 
Be  in  the  closest  touch  with  the  subject,  allowing  not  a  single  break 
in  that  subtle,  intuitive  current  whereby  we  anticipate  a  move  on 
his  part. 

Don't  scrawl  all  over  the  capsule  and  zonule  with  the  cystotome. 
Take  pains  to  place  the  point  properly  on  the  cataract  just  where 
the  opening  should  begin — not  hastily;  elevate  the  handle  until 
the  point  is  sure  to  have  engaged  the  capsule,  then  draw  it  very 


THE    TOILET  517 

lightly  along,  making  a  definite  cut,  and  note  that  the  lens  resjionds 
to  the  liberation  by  springing  forward.  If  not,  it  is  better  to  go 
over  it  a  second  time,  there  and  then,  trying  to  improve  upon  the 
lirst  effort,  than  to  be  obliged  to  again  enter  the  instrument. 

Don't  triturate  the  cornea  too  much  with  the  spoon  in  delivering 
the  cataract,  nor  rub  it  about  in  an  aimless  sort  of  way  to  get  out 
the  cortex.  Be  sure  that  tlie  back  and  not  the  cdi^r  of  iIk'  instrument 
is  applied.  Don't  stop  to  ])ick  up  the  extracted  lens  unless  it  is 
caught  deftly  upon  the  U])per  spoon-  -merely  brush  it  aside  until 
the  operation  is  terminated. 

Don't  have  the  instruments  drip])ing  wet,  as  the  liquid,  streaming 
downward,  carries  bacteria  from  the  lingers  to  the  eye.  Don't  hold 
instruments  in  the  mouth  to  disembarrass  the  hands.  Give  them 
to  an  assistant  or  lay  them  down. 

Don't  talk  any  more  than  necessary,  and  never  with  exj)losive 
aspiration,  to  emit  showers  of  germs,  even  though  mouth  and  nose 
be  covered  by  a  mask. 

It  is  the  better  part  of  wisdom  to  close  and  bandage  the  eye  as 
soon  as  practicable  after  the  extraction  of  the  cataract,  and  to 
discourage  all  unnecessary  movement  or  turning  of  it.  With  this  in 
view,  little  exhibitions  like  having  the  patient  count  the  operator's 
lingers  or  to  tell  the  time  on  a  watch,  through  a  convex  lens,  it 
is  deemed  prudent  to  omit.  Such  things  were  formerly  supposed 
to  be  a  test  as  to  whether  any  portions  of  the  cataract  were  left 
behind,  but  as  such  the  performance  is  a  delusion.  True,  of 
Montpellier,  tells  of  a  lesson  taught  him  in  this  connection.  Think- 
ing to  encourage  a  woman  from  whose  eye  he  had  just  removed  a 
cataract,  had  her  count  his  fingers.  In  the  exuberence  of  her  joy 
she  became  convulsi\c,  gave  a  tremendous  squeeze,  forcing  out  the 
iris  and  most  of  the  \  itreous.  The  consequence  was  total-blind- 
ness in  both  eyes— that  of  the  unopcrated  one  from  sym])athctic 
ophthalmia. 

The  Toilet  of  the  Eye. — Having  seen  to  it  that  no  part  of  the 
iris  is  caught  in  llie  wound  nor  in  any  manner  disarranged,  and  that 
the  lips  of  the  cut  are  nicely  in  apposition,  gently  sponge  away  all 
the  loose  debris,  cortical  matter,  etc.,  carefully  remove  any  shreads 
of  librinated  blood  from  about  tlie  incision  with  the  toilet  forceps, 
and  arrange  the  conjunctival  llap.  Flow  a  dropperful  or  two  of 
warm  boric  acid  solution  over  the  eye  and  close  the  lids.  Instead 
of  ordering  the  patient  to  do  this  last,  the  operator  will  often  do 


5l8  EXTRACTION  OF  CATARACT 

well  to  perform  the  act  himself,  usually  by  taking  hold  of  the  lashes, 
lifting  the  lid  slightly  and  shutting  it.  Docile  patients,  however, 
may  be  trusted  to  do  it  unaided,  but  must  be  warned  against  forcible 
closure. 

Dressing  of  the  Eye.  A  lamina  of  absorbent  cotton,  almost  as 
thin  as  a  veil  and  about  two  inches  square,  is  made  sopping  wet 
with  warm  boric-acid  solution  and  laid  on  the  lids  rather  high  up 
(see  chapter  on  "Dressings"),  then  pulled  down  into  place.  In 
this  manner  the  lashes  are  smoothed  out— not  crumpled  up  in  the 
dressing.  Although  this  may  seem  a  trivial  item,  it  is  really  an 
important  one,  both  for  the  patient's  comfort  and  for  the  good  of 
the  eye.  This  first  layer  of  cotton  is  so  thin  that  when  the  air  is 
squeegeed  out  by  a  cotton  sponge,  which  causes  it  to  adhere  evenly, 
the  skin  and  lashes  can  be  plainly  seen  through  it.  The  direction 
of  the  cotton  fibres  should  be  vertical.  The  boric  acid  solution 
with  which  it  is  moistened  is  made  from  the  impalpable  powder 
and  should  be  more  than  saturated;  in  other  words,  there  should 
be  an  extra  quantity  of  the  powder  in  suspension  so  that  the  meshes 
of  the  cotton,  upon  drying,  will  be  filled  with  it.  Gauze  or  any 
woven  material  is  not  put  next  to  the  lids  because  the  twisted  threads 
are  more  or  less  hard  and  press  into  the  delicate  skin.  Neither 
is  sublimate  solution  used  for  moistening  the  cotton  for  the  reason 
that  it  would  be  found  irritating  to  the  lids  of  many  patients.  Over 
the  wet  cotton,  a  thick,  soft  pad  of  dry  cotton  is  carefully  built  up 
so  as  to  give  an  equal  pressure  under  the  bandage  at  every  point. 
The  bandage  of  netting,  wet  with  boric  acid  or  sublimate  solution, 
is  then  applied  as  per  the  method  described  elsewhere  and  fastened 
with  ordinary  pins.  A  wrongly  constructed  pad,  or  a  too  tightly 
or  unevenly  drawn  bandage  will  cause  discomfort  and  tend  to  pre- 
vent prompt  healing  of  the  incision. 

Thanks  to  an  idea  lately  hit  upon  by  Dr.  Fullenwider,i  one  of 
our  internes  at  the  Illinois  Charitable  Eye  and  Ear  Infirmary,  never 
is  there  any  more  slipping  or  displacement  of  the  dressing  nor  even 
a  chance  for  the  patient  to  finger  the  eye  beneath  the  cotton  pad. 
As  soon  as  the  bandage  is  applied,  a  quantity  of  flexible  collodion 
is  painted  on  where  the  folds  cross  the  forehead  and  cheek  and  a 
strip  of  gauze  is  laid  on  the  nose  and  cheek,  extending  up  onto  the 
dressing  and  similarly  smeared,  to  bar  any  meddling  with  the  eye 

'  I  have  since  learned  that  collodion  was  used  in  a  similar  way  by  De 
Wecker,  of  Paris,  some  years  ago. 


AFTER-TREATMENT  5  '  9 

on  the  part  of  the  i)aticnl's  fingers.  The  coUocHon  sets  immediately, 
even  on  the  wet  netting,  and  holds  beautifully.  One  of  the  stiff 
shields  or  masks  may  be  tied  on,  such  as  Ring's,  or  the  aluminum 
mould.  The  latter  can  be  more  conveniently  and  effectively  sterilized. 
As  the  writer  bandages  only  the  one  eye,  save  in  exceptional  cases, 
if  the  shield  is  for  both  eyes,  a  large  hole  is  made  in  that  part  over 
the  unoperated  eye  for  the  patient  to  see  through.  He  is  told  to 
keep  both  eyes  shut  most  of  the  time,  only  opening  the  free  eye 
when  it  is  absolutely  necessary.  With  a  few  the  emergency  will 
often  arise,  but  with  the  majority  not  at  all.  In  case  after  case 
when  it  comes  to  the  first  dressing,  the  unbandaged  eye  will  be 
found  to  have  its  lids  firmly  glued  together  by  old,  dried  secretions. 

After-treatment.— While  yet  on  the  operating-table,  it  is  well 
to  give  the  patient  a  few  parting  instructions.  He  is  told  that  he 
must  keep  very  quiet  in  bed  for  a  short  time,  that  it  will  not  be 
long  before  he  will  be  allowed  to  sit  up.  That  he  must  remember  all 
the  while  that  he  is  in  the  hands  of  his  friends,  that  night  and  day 
there  is  someone  within  easy  call,  etc.,  all  of  which  has  the  effect 
of  reassuring  him,  particularly  if  he  can  be  truthfully  informed  of 
the  success  of  the  operation.  He  is  warned  against  stooping  or 
straining,  and  told  that  he  may  turn  about,  quietly,  to  assume 
different  positions  of  lying — on  back,  side  of  unoperated  eye,  and 
even  a  little  to  the  side  of  the  operated  one,  so  long  as  he  doesn't 
press  the  dressing  upon  the  pillow. 

On  the  journey  from  the  operating-room  to  the  bed,  I  prefer  to 
have  the  patient  walk  to  having  him  lifted— often  by  untrained 
assistants — to  and  from  a  stretcher  or  cart.  He  is  helped  to  a  sitting 
posture  on  the  table,  with  his  feet  hanging,  then  an  attendant 
stands  on  either  side,  each  wuth  one  hand  beneath  the  patient's  arm- 
pit and  the  other  holding  his  wrist  or  hand,  when  he  slides  down 
until  he  is  standing  on  the  floor  and  is  led  to  his  room.  There  he 
is  told  to  sit  on  the  edge  of  the  bed  while  shoes,  stockings,  and 
outer  dress  are  taken  off  by  an  attendant,  being  prevented  from 
attempting  to  help  in  the  disrobing.  Having  been  duly  put  to  bed, 
he  is  again  assured  that  there  are  always  near  him  those  whose  duty 
and  pleasure  it  is  to  answer  his  calls  and  attend  to  his  wants. 

A  moderate  amount  of  light  is  admitted  to  the  room,  and  a  shaded 
lamp  is  allowed  at  night.  To  have  the  privilege  granted  him  of 
changing  his  position  from  time  to  time  as  he  lies  there  is  a  great 
boon,  especially  to  the  elderly  subjects,  and  prevents  many  complica- 


520  EXTRACTION  OF  CATARACT 

tions  (one  being  hypostatic  pneumonia)  while  it  causes  none.  But 
to  be  enjoined  from  moving^ — told  even  that  he  must  lie  very  still — 
is  terrible  for  the  average  individual.  He  gets  a  notion  that  the 
slightest  move  would  be  disastrous,  and  the  restraint  is  torture.  All 
manner  of  aches  and  other  physical  disturbances,  including  flatulence 
of  the  bowels,  accumulation  of  gases  in  the  stomach,  etc.,  are  inevi- 
table. Another  occasional  effect  of  the  operation  is  to  cause  reten- 
tion of  urine,  and  the  function  of  the  bladder  must  be  looked  after. 
If  there  be  retention,  a  few  catheterizations  are  sufficient  to 
reestablish  the  function.  The  subsequent  after-treatment  is 
pretty  well  laid  down  in  the  chapter  on  Consecutive  Accidents  and 
Complications. 

The  First  Dressing. — If  all  goes  well,  the  bandage  is  left  in 
place  for  forty-eight  hours.  This  will  have  given  time  for  normal 
primary  closure  or  healing  of  the  wound.  x\t  the  end  of  this 
period,  no  matter  how  favorable  the  progress,  the  eye  is  inspected. 
The  undressing  of  an  eye  requires  as  much  care  as  the  dressing. 
According  to  the  statement  which  has  already  been  made  (see 
chapter  on  Consecutive  Accidents  and  Complications),  extrusion 
or  entanglement  of  the  iris  is  not  an  infrequent  occurrence  at  the 
first  dressing,  and  the  explanation  is  as  follows : 

When  one  raises  the  upper  lid  to  open  an  eye  that  has  been 
bandaged  and  the  light  strikes  in,  if  great  caution  is  not  exercised, 
there  is  a  sudden  spasm  both  of  the  superior  rectus  and  of  the 
orbicularis,  the  wound  is  opened,  there  is  a  rush  of  aqueous,  the 
iris  is  washed  out,  and  when  the  cut  is  examined,  a  prolapse  is 
found.  This  fact  furnishes  an  argument,  therefore,  for  letting  the 
eye  alone  if  all  seems  to  be  going  well  until  time  endligh  has  elapsed 
to  insure  permanent  closure  of  the  incision.  This,  on  the  other 
hand,  may  be  effectively  answered  by  the  counter  proposition 
that  the  mere  fact  that  the  patient  is  uncomplaining,  is  not  conclusive 
evidence  that  all  is  going  well.  While  house  surgeon  at  the  Man- 
hattan Eye  and  Ear  Hospital,  which  was  in  the  days  when  it  was 
the  custom  of  most  operators  not  to  rcmo\e  the  first  dressing  for 
six  or  seven  days,  I  saw  complete  breaking  down  of  the  cornea 
of  a  stolid  male  cataract  patient  from  infection.  The  poor  fellow 
had  been  as  contented  as  could  be  ever  since  the  operation,  and 
although  he  had  been  repeatedly  asked  how  the  eye  felt,  his  replies 
were  uniformly  faxorable. 

Preventives.     'I'lic  strongest  argument,  therefore,  would  be  that 


FIRST    DRESSING  52I 

we  should  use  the  utmost  prudence  in  the  handling  of  these  cases, 
as  to  the  nursing,  the  dressing,  and  the  examining  of  them.  The 
patient  is  made  ready  for  the  dressing  by  a  few  assurances  that  the 
eye  is  only  to  be  looked  at,  "no  hurting,  etc.,"  and  by  instruction 
not  to  open  the  eyes  until  told  to  do  so,  never  to  squeeze,  etc.  As 
to  the  kind  of  light  employed,  it  may  be  either  soft,  diffuse  daylight 
or  focal  illumination  from  moderate  lamp  flame  or  gas  jet  held  to 
the  side. 

Where  practicable,  the  first  dressing  should  l)e  willi  the  patient 
in  his  bed.  With  strong  scissors  made  for  the  purpose,  the  bandage 
is  cut  on  the  side  opposite  to  that  of  the  operated  eye.  It  is  then 
lifted  just  enough  to  allow  of  the  fingers  being  placed  upon  the 
edges  of  the  cotton  pad  which  lies  upon  the  lids.  This  is  to  hold 
the  pad  in  place  while  the  bandage  is  stripped  off.  After  this,  if 
there  is  the  least  tendency  of  the  cotton  to  stick,  a  little  warm  boric 
acid  solution  is  dropped  in  behind  it.  The  cotton  removed,  the 
lids  of  both  eyes  are  gently  wiped  with  a  cotton  sponge  from  which 
the  boric  acid  solution  has  been  so  squeezed  that  the  sponge  takes  or 
drinks  rather  than  gives.  In  this  way  the  soiled  solution  is  drawn 
away  from  the  palpebral  fissure  and  not  driven  inward  through  it. 
At  this  point,  if  the  patient  is  nervous,  a  drop  of  cocain  solution 
should  be  instilled,  as  it  will  greatly  facilitate  the  inspection.  After 
waiting  for  he  anesthesia  the  patient  is  quietly  asked  to  open  the 
eyes,  and  the  thumb  is  placed  on  the  brow  to  elevate  the  upper  lid 
having  as  a  base  the  rim  of  the  orbit  of  the  operated  eye.  Now,  with 
the  light  full  on  the  eye,  the  patient  is  told  to  look  down  or  at  an 
object  held  for  the  purpose. 

One  should  not  be  content  with  a  cursory  insi)cction,  but  would 
better  look  closely,  even  with  the  aid  of  a  strong  convex  lens  or  the 
stereoscopic  loup,  to  make  sure,  as  otherwise  faint  signs  of  impend- 
ing trouble  might  be  overlooked.  So  long  as  nothing  untoward 
appears  no  collyria  are  employed.  The  eye  is  dressed  precisely 
as  before,  and  every  day  thereafter  the  same  examination  and  re- 
dressing are  repeated  so  long  as  bandaging  is  necessary,  which,  in 
favorable  cases,  is  about  one  week. 

For  a  day  or  two  after  the  first  dressing,  the  patient  is  permitted  to 
sit  part  of  the  time  in  a  chair  and,  at  the  end  of  three  or  four  days,  to 
walk  about  the  room.  If  he  has  made  normal  progress  and  lives 
near  by,  he  is  discharged  from  the  hospital  in  about  ten  days,  but  is 
kept  under  observation  until  the  eye  is  perfectly  quiet  or  free  from 


522  EXTRACTION  OF  CATARACT 

any  redness.  When  the  bandage  is  left  off,  a  shade  is  substituted 
or  medium  smoke  coquilles.  The  spherical  lens  that  gives  the  best 
visual  result  is  fitted  in  two  weeks  to  a  month  from  the  time  of  the 
extraction. 

ACCIDENTS  AND  COMPLICATIONS. 

The  accidents  and  complications  that  may  occur  in  connection 
with  extraction  are  divided  into  immediate  and  consecutive,  the 
former  having  reference  to  those  that  are  incident  to  the  operation 
itself,  and  the  latter  to  those  that  may  involve  the  after-treatment. 
In  either  instance,  when  they  arise,  their  origin  may  be  due  to  one 
of  a  number  of  causes.  Lack  of  skill,  care,  or  experience  on  the 
part  of  the  surgeon  must  stand  first  in  the  list  of  causes.  Next  in 
prominence,  perhaps,  comes  v/ant  of  control  and  ignorance  on  the 
part  of  the  patient.  Third,  incompetency  and  neglect  on  the  part  of 
assistants,  and,  lastly,  a  whole  group  of  causes  for  which  no  one  may 
be  held  responsible.  In  this  chapter,  therefore,  an  attempt  will  be 
made  to  enumerate  the  various  undesirable  happenings  and,  in  so 
far  as  possible,  to  suggest  appropriate  preventives  and  remedies; 
for  they  all  incline  to  embarrass  the  operator  and  to  jeopardize  his 
ultimate  success. 

Reviewed  in  the  order  of  occurrence  they  are: 

IMMEDIATE. 

1.  Accident. — Over  or  prolonged  cocainization,  causing  drying 
and  exfoliation  of  corneal  epithelium,  bleeding  from  conjunctival 
flap,  hypotonicity  of  the  globe,  collapse  of  the  cornea,  and  delayed 
union  of  the  lips  of  the  wound. 

Preventive.-  -Use  only  two  to  four  dro})s  of  a  4'^^  solution. 
Keep  the  lids  closed  and  covered  with  wet  cotton  between  whiles,  so 
as  to  prevent  drying  of  cornea,  and  make  the  operation  under  the 
])rimary  effect  of  the  drug. 

Remedy. — Defer  the  operation  until  another  day  or  the  next  day. 

2.  Accident. — Touching  the  eye  with  the  lingers. 
Preventive.     Obvious. 

Remedy.  Douche  the  eye  copiously  with  warm  boric  acid  solu- 
tion. 

3.  Accident.  -Allowing  the  kni/'e  or  any  instrument  to  touch  cilia, 
skin  or  any  object  other  tlum  that  desired. 


IMMEDIATE    ACCIDENTS  523 

Preventive. — Obvious. 

Remedy. — Immedialcly  either  lake  a  fresh  inslrumenl  or  cause 
that  one  to  be  again  disinfected.  Or,  if  the  accident  hapjjens  while 
using,  as  knife,  for  instance,  try  to  keep  the  portion  contaminated 
from  entering  the  eye. 

4.  Accident. — The  serio-comic  (Hlemma  oijiiidiiig  that  the  knije- 
hlade  has  been  inserted  upside  douii. 

Preventive. — Obvious. 

Remedy. — Knap])^  advises  that,  without  withdrawing,  the  knife 
be  simply  turned  i8o°  on  its  long  axis,  thus  reversing  the  position  and 
continuing  the  section.  He  states  that  the  accident  has  happened 
to  him  four  times  and  that  there  has  never  been  any  reaction  seen 
from  it.  He  doesn't  say  that  he  resorted  to  this  redress  in  each 
instance,  but  such  is  the  inference.  Now,  every  man  is  not  a  Knapp, 
and  the  writer  would,  in  view  of  this  accident,  counsel  postponement 
of  the  operation  for  at  least  twenty-four  to  forty-eight  hours.  Given 
a  deft  hand  and  a  very  narrow  knife,  this  feat  of  turning  the  blade 
might  be  attempted  but,  having  accomplished  it,  if  the  anterior 
chamber  is  found  empty,  it  were  better  to  desist  for  the  moment 
from  pushing  the  operation  further. 

5.  Accident. — Engaging  the  point  of  the  knije  in  the  iris  just 
after  making  the  puncture. 

Preventive. — Depress  the  handle  immediately  the  point  enters 
the  anterior  chamber,  so  as  to  clear  the  iris. 

Remedy. — Withdraw^  the  knife,  without  changing  its  direction, 
just  enough  to  release  the  point,  and  continue. 

6.  Accident. — Starting  the  counter  puncture  too  far  hack  or  too  far 
forward. 

Preventive. — Better  light,  and  bearing  in  mind  that  owing  to  the 
refractive  media  through  wdiich  we  see  the  blade,  it  seems  to  be 
nearer  to  us,  or  higher,  than  it  really  is. 

Remedy. — Same  as  for  No.  5. 

7.  Accident. — Pressing  the  jaws  of  the  fixation  forceps  into  the 
globe  during  the  making  of  the  cut,  forcing  out  the  aqueous  and 
causing  premature  emptying  of  the  anterior  chamber. 

Preventive.— Rest  the  little  linger  of  the  hand  that  holds  the 
forceps  firmly  on  the  patient's  nose  or  cheek  and  do  not  altogether 
lose  sight  of  what  that  hand  is  doing,  else  not  only  is  this  accident 
more  probable,  but  one's  grip  of  the  forceps  is  apt  unconsciously  to 

1  Norris  and  Oliver  System,  p.  800. 


524  EXTRACTION  OF  CATARACT 

relax  and  leave  the  globe  free  to  turn.  To  insure  firmness,  the  bite 
of  the  forceps  should  include  the  episcleral  tissue. 

8.  Accident. — Rising  of  the  iris  in  front  of  the  edge  of  the  knife. 
Preventive.— Attention   to  fixation  forceps.     Avoidance  of  all 

unnecessary  alterations  in  the  cutting  plane  which  pry  open  the 
incision  and  spill  the  aqueous.  See  to  it  at  the  time  of  making 
puncture  and  counterpuncture  that  the  blade  lies_^o/  upon  the  iris, 
as  to  turn  the  edge  backward,  risks  to  engage  that  membrane. 

Remedy. — Seeing  that  the  iris  is  overlapping  the  knife,  some- 
times a  slight  turning  forward  of  the  edge  or  lightly  lifting  the  entire 
instrument  will  free  it,  albeit  the  first  maneuver  causes  the  incision 
to  end  somewhat  further  within  the  limbus  than  was  intended. 
If  these  fail,  nothing  is  left  but  to  cut  boldly  ahead  as  if  nothing 
were  in  the  way.  The  result  may  be  a  buttonhole,  a  clean  coloboma, 
or  some  irregular  form  of  iridectomy.  In  any  case  make  sure  that 
there  remains  neither  pupillary  bridge  nor  dangling  fragment,  before 
proceeding  with  the  operation. 

It  is  not  humiliating  for  a  surgeon  to  confess  that  he  does  not 
always  accomplish  just  what  he  plans  or  desires  in  this  operation, 
whatever  his  skill  and  experience.  In  this  connection,  for  example, 
an  exceedingly  shallow  anterior  chamber  may  thwart  the  making  of  a 
classic  incision.  Again,  an  unruly  or  restive  patient  may  baffle 
the  most  practised  hand. 

9.  Accident. — Splitting  of  the  cornea.  The  best  form  of  cor- 
neal incision  has  already,  to  a  certain  extent,  been  dwelt  upon. 
Suffice  it  here  to  reiterate  that  the  best  apposition  is  obtained  and 
the  kindliest  healing  assured  where  the  outer  and  inner  wound 
opening  are  not  widely  separated  and  where  the  summit  of  the 
incision  is  neither  very  far  within  the  limbus  nor  decidedly  back  of  it. 
Those  who  have  not  the  good  fortune  to  operate  frequently  for 
cataract  are  prone  to  magnify  the  snares  and  pitfalls,  hence,  in 
making  the  puncture,  dreading  to  become  entangled  in  the  iris, 
they  depress  the  handle  of  the  knife  too  soon  and,  in  pushing  the 
point  further,  they  observe  a  dim|)lc  a])j^car  in  the  cornea  o\"cr  the 
blade  and  then  realize  that  they  are  splitting  that  membrane. 

Remedy. — Since  the  anterior  chamber  has  not  been  entered, 
witlidraw  the  knife  completely  and  begin  o\er. 

Then,  in  making  the  counterpuncture,  they  liave  ])ainfully  in 
mind  that  illusive  refraclion  of  the  cornea  and  aqueous,  and  make 
it   loo  high   up.     Continuing,   so  very  solicitous    are  they  lest  the 


IMMEDIATE    ACCIDENTS  525 

iris  "falls  in  front  of  the  knife,"  that  they  steer  far  above  it  and 
again  split  the  cornea  on  emerging.  Thus  is  made  a  long  "wound- 
canal"  which  greatly  involves  matters.  To  begin  with,  its  inner 
opening  is  likely  to  be  too  narrow  for  the  ready  passage  of  the  lens, 
while  the  long  projecting  nether  lip  forms  a  shelf  which  interferes 
with  the  work  of  attending  to  iris  and  cortex.  These  attenuated 
lips,  moreover,  impair  the  healing  quality  of  the  wound  because  they 
are,  of  necessity,  poorly  nourished — leading  to  gray  infiltration, 
necrosis,  "grooving,"  nests  for  bacteria,  and,  ultimately,  broad  and 
contracted  cicatrices. 

10.  Accident. — Including  icilli  the  section  rather  large,  lateral, 
conjuHctii'al  flap. 

Preventive. — Observe  the  rules  already  given  for  the  iixalion 
of  the  globe,  though  if  it  should  occur  pay  no  attention  to  it  so  long 
as  the  incision  is  not  too  far  back.  It  merely  increases  the  chances 
of  the  following: 

11.  Accident. — Bleeding  into  the  Anterior  Chamber.  The 
presence  of  any  considerable  hemorrhage  in  the  anterior  chamber 
at  this  stage  is  objectionable  because  it  obscures  the  field  of  sub- 
sequent operation. 

Preventive. — Avoid  too  large  a  conjunctival  flap  and  too  pro- 
longed cocain  effect. 

Remedy. — Flood  the  eye  gently  with  warm  boric  acid  solution 
and  stroke  the  cornea  softly  with  the  back  of  the  Graefe  spoon, 
applying,  the  while,  a  pointed  cotton  sponge  to  the  incision,  and  the 
blood  will  usually  come  out.  If  necessary  depress  the  posterior 
lip  of  the  cut,  or  insert  the  tip  of  the  spatula  while  stroking  upward 
with  the  spoon.  If  this  does  not  accomplish  the  removal  of  the 
blood,  a  flattened  canula  attached  to  a  bulbous  aspirator  may  be 
used.  The  cannula  should  be  sterilized  in  the  flame  of  a  spirit  lamp, 
as  it  is  very  difficult  to  sterilize  a  small-bored  instrument  by  other 
methods.  It  is  better  surgery,  however,  to  leave  a  little  blood  in 
the  anterior  chamber  than  resort  to  the  cannula,  for  every  addi- 
tional instrument  introduced  into  the  eye  adds  to  the  danger  of 
infection. 

12.  Accident. — Air  in  the  anterior  chamber.  After  introducing 
the  cystotome,  we  sometimes  become  aware  of  a  bubble  of  air  in  the 
anterior  chamber.  This  comes  from  lifting  the  corneal  flap,  while 
introducing  the  instrument,  and  causing  a  vacuum  beneath.  The 
same  accident  may  occur  through  inserting  the  forceps  for  iridec- 


526  EXTRACTION  OF  CATARACT 

tomy.  It  may  be  prevented  by  gliding  the  aforesaid  instruments  in 
more  deftly. 

Remedy. — A  few,  gentle,  upward  strokes  of  the  back  of  the  spoon 
upon  the  cornea  will  usually  drive  it  out.  Though  if  some  of  it  be 
left  behind  it  is  not  supposed  to  be  harmful,  as  it  is  soon  absorbed. 
However,  in  an  otherwise  perfectly  normal  extraction  performed 
by  the  author,  in  which  this  accident  occurred,  the  operation  was 
followed  by  panophthalmitis,  although  the  air  was  immediately 
removed  in  the  manner  just  described.  Therefore  it  appears  safer 
to  irrigate  the  anterior  chamber  after  such  an  accident,  in  order  to 
thoroughly  wash  out  any  infection  introduced  by  this  bacteria-laden 
bubble  of  air. 

13.  Accident. — Failure  to  make  capsulotomy  comes  of  either  a 
dull-pointed  cystotome  or  of  so  depressing  the  handle  that  the  con- 
vexity of  the  lens  prevents  contact  of  the  point  with  the  capsule. 
Or  the  capsule  may  be  too  tough,  in  which  case,  particularly,  if 
the  zonule  is  weak  and  the  vitreous  is  fluid,  the  cataract,  capsule, 
and  all  will  simply  be  depressed  beneath  the  instrument  or  move 
with  it  in  attempting  to  make  the  cut,  no  matter  how  sharp  the 
cystotome. 

Through  too  much  grinding  the  cystotome  often  loses  it  proper 
form  or  model  and  becomes  an  insignificant  remnant — an  anomaly 
— and  then  it  should  be  discarded.  The  surgeon  should  be  as 
exacting  as  to  shape  and  keenness  in  the  cystotome  as  in  the  knife. 

Too  much  caution  in  making  the  capsulotomy  cannot  be  exercised. 
Actual  pression  is  inexcusable.  There  is  no  step  of  this  very  delicate 
operation  of  extraction  that  so  strongly  exacts  a  fine  sense  of  touch. 
If  one  does  not  sense  nicely  the  force  of  the  scratch,  he  zonule  is 
torn  and  the  ciliary  processes  are  lacerated.  By  watching  closely, 
one  may  in  most  cases  be  assured  of  a  complete  incision  in  the 
capsule  by  seeing  the  cataract  suddenly  rise.  Yet,  as  this  is  not 
always  apparent,  he  may  be  unaware  of  his  failure  until,  in  attempt- 
ing to  express  the  lens,  that  body  refuses  to  respond  to  the  wonted 
])ressurc. 

The  remedy  consists  in  again  going  through  the  act,  this  time 
being  more  careful  as  to  the  condition  and  manipulation  of  the 
instrument. 

It  may  chance  in  essaying  the  capsulotomy  that  the  cataract  is 
observed  to  follow  the  movements  of  the  cystotome.  This  indicates 
a  tough  capsule  or  a  ruptured  zonule  or  both,  and  one  must  be 


IMMEDIATE    ACCIDENTS  527 

extremely  wary  in  the  delivery  of  the  lens  lest  there  be  escaj^e  of 
vitreous.  If  it  is  quite  evident  that  the  capsule  cannot  be  cut 
sufficiently  without  luxation  of  the  lens,  recourse  may  be  had  to  the 
capsulotomy  forceps.  If  these  extract  only  the  capsule  and  not  the 
cataract  with  it,  the  open  sharp  hook  would  be  the  writer's  preference 
as  the  traction  instrument  to  use.  First,  however,  unless  the  pupil 
behaved  unusually  well,  it  were  safest  to  make  iridectomy. 

14.  Accident. — Inadequate  wound  opening.  The  causes  of  this 
have  been  previously  enumerated.  Like  the  incomplete  cystotomy, 
the  operator  does  not  always  realize  the  presence  of  it  until  the  lens, 
while  presenting  in  a  normal  manner,  yet  fails,  even  with  pretty  firm 
pressure,  to  advance.  The  signs  of  an  insufficient  section  are  un- 
mistakable, however,  as  soon  as  the  spoons  are  applied  and  the 
wound  yawns,  for  then  the  small  inner  opening  is  brought  to  view, 
against  which  the  lens  bumps  ineffectually,  and  to  unduly  force  its 
exit  would  be  most  prejudicial,  as  even  should  the  eft'ort  succeed, 
the  iris  and  cornea  would  be  wantonly  bruised  and  the  cataract 
would  probably  be  shot  out  by  an  explosion  of  vitreous. 

The  fault  may  be  one  of  several.  The  remedy,  however,  is  to 
enlarge  the  incision,  which  may  be  done  either  with  sharp-edged  and 
blunt-pointed  knife  (Desmarres)  or  with  scissors.  The  smallest 
blunt-pointed  strabismus  scissors,  curved  on  the  flat,  are  excellent 
for  the  purpose. 

iv  Accident. — Rigidity  of  the  pupil.  This  rarely  occurs  if 
there  has  been  fair  mydriasis  when  the  operation  was  begun. 
The  pupil  does  not  always  respond  to  the  atropin.  In  any  event, 
if  the  sphincter  does  not  yield  to  rather  prolonged  pressiu-e — moder- 
ately applied,  for  there  is  no  need  to  hurry — perhaps  the  wisest 
alternative  is  to  make  a  small,  one-snip  iridectomy  which  comprises 
little  more  than  the  sphincter  itself.  Knapp  recommends  first 
trying  to  push  the  iris  back  over  the  lens  with  the  wire  loop;  and 
Panas  practised  snipping  of  the  pupillary  border  with  the  De  Wecker 
forceps-scissors — both  are  masters  in  their  art  and  wholly  worthy  of 
emulation. 

16.  Accident. — Erratic  behavior  of  the  lens.  Cataracts  with 
small,  hard,  or  discoid  nuclei,  especially  those  with  degenerated 
liquid  cortex  and  frail  zonules  or  shrunken  lenses,  are  apt  to  prove 
capricious  when  we  try  to  drive  them  out.  One  of  their  peculi- 
arities is  to  become  agglutinated  to  the  posterior  surface  of  the  cornea, 
as  if  by  suction,  and  so  long  as  the  lower  spoon  is  pressed  below  the 


528  EXTRACTION  OF  CATARACT 

cornea,  the  lens  will  not  budge.     If  the  condition  be  not  recognized 
at  once  and  tactics  changed,  a  gush  of  vitreous  is  sure  to  follow. 

The  remedy  is  merely  to  slide  the  spoon  up  onto  the  cornea, 
dislodge  the  cataract,  and  push  it  out. 

Another  freak  of  such  cataracts  is  to  slip  up  behind  the  iris, 
or  even  wdiere  iridectomy  has  been  made  the  upper  edge  of  the  lens 
may  lodge  behind  the  incision.  This,  too,  exposes  to  turning  over 
of  the  lens  and  vitreous  escape. 

The  remedy  which  has  always  served  the  writer  in  this  emergency 
is  to  push  the  crystalline  down  by  means  of  the  little  iris  spatula, 
then  to  proceed  with  the  delivery  in  the  regular  w^ay.  Others 
favor  the  cystotome,  but  the  spatula  is  easier  of  insertion  and  quite 
effectual.     Failing  with  this,  the  open  sharp  hook  is  the  thing. 

Again,  there  is  a  class  of  pasty,  sticky  cataracts  that,  in  spite  of  an 
ample  incision,  will  hang  and  choke  the  opening,  and  if  urged  too 
strongly  may  pop  out  suddenly,  entraining  loss  of  vitreous. 

The  remedy  is,  while  the  operator  applies  just  enough  force  to 
hold  the  mass  well  up,  for  a  handy  assistant  to  dig  the  cystotome  or 
sharp  hook  into  the  edge  and  deliver  it  by  a  sort  of  sidewise  rolling 
motion.  Or  the  operator  himself  may  do  this  with  the  edge  of  one 
spoon  while  holding  the  lens  up  by  pressure  with  the  other.  It 
only  remains  in  this  connection  to  discuss  that  rather  startling 
vagary, 

The  Sinking  of  the  Cataract  into  the  Vitreous.— Fortunately,  a 
very  rare  complication,  but,  when  met,  the  operator  must  be  prompt 
to  act  or  all  is  lost.  I  have  seen  one  of  the  most  skilled  and  tact- 
ful ophthalmic  surgeons  the  world  has  ever  produced  fail  utterly 
to  deliver  such  a  recalcitrant  lens,  and  have  seen  others,  almost  as 
proficient,  reduce  the  globe  to  a  hopeless  wreck  when  confronted 
with  the  accident.  One  of  them  placed  the  left  thumb  behind  the 
incision  and  the  right,  beneath  the  cornea  and  then  approximated 
them,  expelling  cataract,  vitreous  body,  and  all.  The  cause  of  this 
occurrence  is  usually  the  complete  tearing  away  of  the  zonule  in  an 
eye  with  liquid  vitreous. 

Various  instruments  have  been  used  and  advised  for  reclaiming 
the  lens  under  these  conditions,  as  also  for  delivering  it  when  the 
vitreous  is  presenting  or  escaping;  these  include  almost  all  the 
spoons,  hooks,  loops,  and  scoops  from  Daviel's  down.  The  fenes- 
trated spoon  of  V.  Gracfe,  the  delicate  wire  loops  of  Weber  and 
Snellen,  and  the  vectis  of  Taylor,  each  of  ihcm  has  stood  its  advo- 


IMMEDIATE    ACCIDENTS  529 

cates  in  good  stead.  The  writer's  preference,  however,  is  for  a 
modification  of  the  harp  hook,  commonly  attributed  to  Tyrell  and 
by  some  to  Jaeger,  but  originated,  I  believe,  by  Beer.  This  sur- 
geon designed  and  employed  the  instrument  as  a  tenaculum  to  draw 
out  the  iris  in  the  operation  of  iridectomy.  The  modification  con- 
sists merely  in  making  the  hook  much  less  curved  than  is  that  of  the 
regular  pattern.  Instead  of  being  bent  back  upon  itself,  like  a  but- 
ton hook,  it  is  about  the  shape  of  a  miniature  strabismus  hook 
(v.  Graefe's  model),  only,  of  course,  sharpened.  This  straighten- 
ing out  of  the  bend  is  to  enable  the  point  to  catch  readily  in  the 
lens  substance,  whereas  the  highly  curved  form  might  slip  off  (see 
chapter  on  Instruments).  With  such  an  instrument,  insinuated  flat- 
wise at  the  opening,  pushed  downward  behind  the  cataract  without 
turning,  until  the  point  is  opposite  to  that  body,  then  turned  for- 
ward and  thrust  into  it,  it  is  surprising  how  easily,  and  with  what 
slight  disturbance  of  the  vitreous,  the  refractory  cystalline  may  be 
slid  along  the  anterior  wall  of  the  globe  and  out  at  the  incision. 
Its  displacing  effect,  as  compared  with  any  kind  of  spoon  or  even 
with  the  wire  loop,  is  practically  nil. 

In  the  event,  however,  of  the  lens  turning  turtle  and  dropping 
entirely  out  of  sight,  the  sharp  hook  should  not  be  plunged  to  the 
very  bottom  of  the  vitreous  chamber,  for  fear  of  its  fouling  the  inner 
tunics  of  the  globe.  If  the  cataract  must  be  "fished"  for— the 
depths  of  the  vitreous  dragged,  as  it  were—then  a  delicate  wire 
loop  would  be  the  safer  instrument  to  employ. 

A  few  ophthalmic  surgeons  of  great  repute,  among  whom  may  be 
mentioned  Snellen,  ^  advise  the  bandaging  of  the  eye  into  whose 
vitreous  the  lens  has  sunken  and  waiting  twenty-four  hours,  when, 
as  was  often  the  case  after  depression,  the  lens  will  probably  have 
returned  to  its  place.  The  wound  is  then  reopened  with  the  spatula 
and  the  cataract  extracted  with  a  traction  instrument,  either  loop 
or  hook. 

17.  Accident. — Presentation  or  prolapse  of  vitreous.  When  this 
occurs  in  the  uncomplicated  cataracts,  it  is  traceable,  as  a  rule,  to 
one  of  two  causes — spasm  of  the  orbicularis,  squeezing  on  the  part 
of  the  patient — or  to  some  fault  in  the  technic  of  the  operator. 
Large  or  prominent  eyeballs  are  peculiarly  liable  to  vitreous  loss 
from  "nipping"  or  from  pressure  of  the  speculum,  for  obvious 
reasons.     Another  cause,  already  alluded  to  (page  107),  is  found 

1  Graefe-Saemisch  Handbook,  Operationslehre,  p.  47. 
34 


530  EXTRACTION  OF  CATARACT 

in  the  bar  of  the  old-style  lid-holder.  Still  another,  the  reclining 
posture  of  the  patient  in  a  chair,  is  said  to  be  attended  more  often  by 
this  accident  than  the  recumbent  one  on  a  table. 

The  preventive  for  the  lirst  is  to  see  that  the  brow  is  properly 
supi)orted  or  the  blepharostat  held  up.  Inexperienced  operators 
would  do  well  to  have  a  trained  assistant  hold  the  lids  apart  with 
retractor  and  fmgers,  dispensing  with  the  blepharostat. 

When  the  blame,  if  it  may  be  so  termed,  rests  with  the  surgeon, 
it  may  be  laid  to  inattention  or  inadvertence  in  some  step  of  the 
operation,  such  as  too  great  pression  upon  the  fixation  forceps  or 
upon  the  cystotome,  to  insufficient  opening  of  the  capsule  or  cornea, 
to  cutting  beyond  the  equator  of  the  lens  in  making  the  capsulotomy, 
etc.  It  may  also  happen  in  our  efforts  to  remove  the  cataract  re- 
mains after  expulsion  of  the  more  consistent  portion  of  the  lens, 
which  will  be  treated  of  later.  We  have  often  heard  eye  surgeons 
declare  that  they  did  not  mind  a  moderate  loss  of  vitreous,  and  we 
have  often  seen  apparently  permanent  good  sight,  etc.,  in  an  eye 
that  had  lost  vitreous  in  the  extraction.  Nevertheless,  it  is  a  danger- 
ous contingency  and  one  most  scrupulously  to  be  avoided.  Not  the 
least  serious  nor  the  least  common  of  its  sequelae  is  extensive  de- 
tachment of  the  retina  and  this  has  a  way  of  creeping  slowly  and 
stealthily,  so  that  months  or  even  years  may  elapse  before  the  worst 
comes. 

Remedy. — Whether  the  vitreous  is  only  on  the  point  of  escaping 
or  is  actually  in  the  act,  the  speculum  must  be  removed  at  once  and 
left  out.  For  the  subsequent  steps  of  the  operation,  the  upper  lid 
should  be  held  back  by  the  finger  or  by  the  Desmarres  retractor. 
It  is  best  to  press  the  lid  up  tightly  beneath  the  roof  of  the  orbit  with 
the  retractor  in  order  to  discourage  any  contraction  of  the  orbicularis. 
If  the  lens  is  still  in  the  eye,  whether  or  not  the  capsule  has  been 
incised,  it  should  be  delivered  with  a  traction  instrument  (the  sharp 
hook  already  referred  to).^  Any  attempt  to  express  it  would  only 
lead  to  further  loss  of  vitreous.  The  cataract  having  been  ex- 
tracted, the  protruding  vitreous  should  be  cut  off  close  to  the  in- 

^I  have  more  recently  arrived  at  the  conclusion  that  there  is  a  less 
radical  and  a  better  way  to  deal  with  some  of  these  cases  of  vitreous  previous, 
if  one  may  be  allowed  the  expression.  Take  for  instance,  one  of  attempted 
simjjlc  extraction  in  which  the  vitreous  comes  before  the  lens.  Instead 
of  resorting  to  the  policy  of  at  once  delivering  the  cataract  at  any  price, 
stop  the  operation,  put  the  eye  in  the  best  condition  possible,  and  apply 
the  dressing.  Then,  by  subsequent  intervention,  with  the  patient  in 
narcosis  and  with  the  help  of  the  Angelucci  fixation  of  the  globe,  there 
may  be  a  much  better  chance  of  saving  the  eye  and  of  restoring  the  sight. 


IMMEDIATE    ACCIDENTS  5 j^  I 

cision  by  means  of  delicate  curved  scissors,  and  llie  iris,  if  prolajjsed, 
should  also  be  cut  off,  as  to  try  to  replace  it  would  most  likely  en- 
tail another  gush  of  vitreous.  If  practicable,  all  vitreous  remains  are 
to  be  flushed  out  of  the  conjunctival  sac  by  copious  warm  irrigation, 
as  they  strongly  invite  infection.  The  sooner  the  wound  can  be  j)Ut 
in  fair  shape  and  the  eye  dressed,  the  better.  Both  eyes  should  be 
carefully  bandaged,  and  the  patient  should  be  kept  very  quiet  for  a 
few  days.  This  subject  will  be  again  considered  under  Extraction 
of  Complicated  Cataracts. 

18.  Accident. — -Extrusion  or  entanglement  of  the  iris  at  the  incision 
is  usually  caused  by  a  sudden  out-gush  of  aqueous.  This  escape  of 
aqueous  is  most  often  produced  by  pressure  upon  the  globe  from 
without,  either  by  the  operator  with  his  instruments  or  by  the 
patient  with  his  orbicularis  It  is  often  quite  an  unavoidable 
occurrence.  If  there  is  an  extensive  prolapse,  especially  if  the  iris 
is  torn,  it  were  best  to  excise  a  small  portion  at  once.  If  there  is 
merely  a  catching  up  of  the  membrane  or  only  a  slight  extrusion 
it  may  be  reduced.  Before  setting  about  it,  it  were  well  to  pause, 
again  closing  the  eye,  and  covering  the  lids  lightly  with  the  wet 
cotton.  When  the  lids  are  opened,  it  is  not  uncommon  to  find  that 
the  iris  has  replaced  itself.  If  not,  a  few  drops  of  the  boric  acid 
solution  are  applied,  and  with  the  spatula,  wet  with  the  solution, 
the  wound  is  softly  patted,  or,  as  advised  by  Knapp,  the  globe  beneath 
the  cornea  is  pressed  upon  in  such  a  way  as  to  cause  the  wound  to 
gape  and  drop  the  iris  from  its  lips.  Failing  in  this  to  restore  it, 
the  spatula  is  introduced  edgewise  at  the  incision,  with  a  sort  of 
slicing  motion,  which  corrects  the  middle  portion.  Then,  if  there 
be  still  any  caught  in  the  angles,  they  are  gently  poked  back  into 
place  with  the  end  of  the  instrument. 

19.  Accident. — Collapse  of  the  cornea.  If  this  membrane  is  very 
thin  and  the  subject  is  aged,  especially  if  much  cocain  has  been 
used,  as  soon  as  the  lens  is  expelled,  the  convexity  of  the  cornea 
becomes  reversed,  a  more  or  less  deep  concavity  taking  its  ])lace. 
This  hampers  the  manipulation  of  lens  remains  and  dealing  with 
the  iris,  and  if  lavage  of  the  anterior  chamber  has  a  place,  this  must 
be  it.  There  could,  at  any  rate,  be  no  objection  to  the  filling  of 
the  anterior  chamber  with  warm  normal  salt  solution  merely  to 
facilitate  maneuvers  relative  to  the  cortex  and  iris.  This  is  not  a 
serious  casualty,  and  usually  all  that  is  necessary  is  simply  to  wait 


532  EXTRACTION  OF  CATARACT 

a  few  minutes  for  the  anterior  chamber  to  retill.  The  eye  should 
be  protected  by  a  piece  of  wet  cotton  in  the  meantime. 

20.  Accident. — Expulsive  or  rctrochoroidal  hemorrhage.  This 
deplorable  calamity,  which  is  always  fatal  to  the  sight  and  usually 
to  the  globe,  though  it  comparatively  seldom  befalls,  comes  to  the 
experienced  operator  and  to  the  tyro  alike,  and  without  warning. 
He,  in  whose  practice  it  has  never  occurred,  has  much  to  be  thankful 
for.  The  writer  is  one  of  these  lucky  individuals,  for  with  a  total 
of  more  than  1,200  extractions,  and  a  still  greater  number  of  iridec- 
tomies, he  has  yet  to  meet  with  this  catastrophe. ^  The  predisposing 
cause  is  usually  degeneration  of  the  vascular  system  (arteriosclero- 
sis) and  the  immediate  cause  is  violence  to,  or  straining  of,  the 
walls  of  the  vessels  through  the  opening  of  the  globe,  causing  a 
rupture.  The  two  long  posterior  ciliary  arteries,  because  of  the 
manner  in  which  they  pierce  the  sclera,  and  owing  to,  the  directness 
of  their  blood  columns,  are  peculiarly  liable  to  this  form  of  hemor- 
rhage. Most  often  the  break  occurs  just  within  the  sclera,  and  it 
is  supposed  to  be  produced  by  the  dropping  away  of  the  vitreous 
after  the  incision  is  made.  Glaucomatous  eyes  are  especially 
subject  to  it,  and,  in  these,  it  is  as  apt  to  follow  iridectomy  as  it  is 
extraction.  It  can  be  classed  among  both  the  immediate  and  the 
consecutive  accidents. 

If  the  bleeding  takes  place  during  the  operation,  the  first  sign  of 
it  is  spontaneous  gaping  of  the  wound.  Then,  if  the  source  of  it 
is  far  back,  either  the  lens  or  the  vitreous  appears.  At  the  same 
time  the  patient  complains  of  great  pain  and  utters  a  series  of 
groans  that  are  of  themselves  distinctive  of  his  misfortune.  This 
groaning  may,  indeed,  be  the  iirst  warning.  Whether  it  be  lens  or 
vitreous  that  first  escapes,  it  is  soon  followed  by  a  gush  of  blood. 
If  the  rupture  is  well  forward,  the  blood  may  escape  in  advance  of 
the  other  structures.  Often  retina  and  choroid  are  eventually 
expelled.  So  great  is  the  force  exerted  by  the  accumulating  hemor- 
rhage, that  once,  for  example,  while  an  onlooker  at  an  operation  of 
iridectomy  for  glaucoma,  I  saw  a  large,  firm  crystalline  (transparent) 
forced  out,  entirely  intact,  through  a  rather  small  kerato'^e  incision. 
Although  in  order  to  make  its  exit,  it  had  to  elongate,  like  an  amcba, 
yet  it  never  halted  for  an  instant.  Patients  with  palpable 
signs  of  arteriosclerosis  should,  in  view  of  the  possibility  of  such 

'  Since  writing  the  above  I  have  had  two  such  accidents — one  48  hours 
after  an  extraction,  the  other  immediately  attending  an  iridectomy 
for  glaucoma. 


IMMEDIATE    ACCIDENTS  533 

hemorrhage,  be  handled  most  gingerly  when  it  comes  to  extraction. 
Especially  should  one  guard  against  sudden  escape  of  a(iucous, 
undue  pression  with  fixation  forceps,  spoons,  or  cyslotome.  and 
pulling  upon  the  iris. 

Prevention. — It  is  prevention  or  nothing.  It  is  safe  to  conclude 
that  most  of  the  victims  of  expulsive  hemorrhage  after  extractions 
and  iridectomies  are  persons  with  degenerated  vascular  systems  and 
abnormally  high  blood  pressure.  Even  normal  arterial  tension  is 
dangerously  great  for  such  operations  with  certain  forms  of  degenera- 
tion. What  more  rational,  then,  along  with  other  preparatory  meas- 
ures, than  to  make  routine  practice  of  testing  the  blood  pressure. 
If  high,  say  above  140  mllm.,and  the  patient's  age  and  general  signs 
make  the  situation  at  all  precarious,  a  course  of  treatment  could, 
with  impunity,  be  given,  calculated  to  lower  the  pressure,  at  least 
for  the  few  critical  days.  Among  the  measures  to  be  resorted  to  are 
blood-letting  by  venesection  (see  chapter  on  "Paraoperative 
Technic"),  free  saline  purgation,  veratrim  viridis,  sodium  nitrite, 
etc.;  though  such  medication  is  of  doubtful  efficacy  in  advanced 
arteriosclerosis.  Continual  tests  are  made  with  the  sphygmoman- 
ometer to  ascertain  if  the  treatment  is  of  any  avail.  When  sufficient 
time  can  be  had  before  the  operation,  the  prolonged  administration 
of  the  iodids  and  the  making  of  a  preliminary  iridectomy  are 
advisable.  The  extraction  should  follow  within  a  few  days  or  a 
week  of  the  iridectomy,  while  the  intraocular  tension  is  still  low. 
Other  precautions  are  narcosis — gas  and  ether,  or,  if  everything  is 
favorable  chloroform— for  the  operation;  and  sedatives,  such  as 
codein,  chloral,  cocain,  or  morphin,  immediately  before  and  after 
the  operation,  and  the  avoidance  of  mydriasis.  Both  eyes  should 
be  snugly  bandaged  after  the  extraction,  a  protective  mask  put  on, 
and  the  patient  be  under  the  constant  surveillance  of  a  trained 
nurse  or  trusted  attendant. 

Remedy. — There  is  little  that  can  be  done.  Remove  all  ex- 
traneous pressure,  cut  off  the  vitreous,  if  prolapsed,  coapt  the 
lips  of  the  wound  as  well  as  possible  and  apply  a  compressive 
bandage  to  both  eyes.  Give  the  sufferer  a  dose  of  morphin  and  put 
him  to  bed  where  he  should  be  placed  in  a  half-reclining  posture. 
The  ukimate  lot  of  the  majority  of  these  eyes  is  enucleation  or 
atrophy  of  the  globe. 

21.  Accident. — Yawning  or  uphcavcl  of  the  lips  of  the  wound.  ■  In 
rare  instances  this  is  apparent  or  else  there  is  a  tendency  for  one 


534  EXTRACTION  OF  CATARACT 

lip  to  override  the  other — vicious  coaptation.  The  former  occurs 
without  actual  presentation  of  vitreous.  De  Wecker  asserts  that  it 
is  sometimes  the  result  of  puncture  of  the  hyaloid  fossa,  in  attempts 
to  rid  the  eye  of  lens  remains,  and  is  due  to  a  rising  intraocular 
pressure  which  may  be  detected  by  palpation,  the  resistance  actually 
increasing  under  the  finger.  Another  symptom  is  the  pushing 
upward  of  the  iris.  He  warns  against  making  further  pressure  on 
the  globe,  as  it  would  precipitate  escape  of  vitreous  and  advises 
immediate  instillation  of  eserin  solution  and  bandaging. 

ACCIDENTS,    ETC.,    CONSECUTIVE    TO    EXTRACTION. 

Prolapse  or  Incarceration  of  the  Iris. — This  is  a  casualty  that 
sometimes  intervenes  between  the  operation  and  the  firm  healing  of 
the  incision,  and  is,  in  most  instances,  produced  by  some  force  that 
causes  the  wound  to  open,  such  as  coughing,  sneezing,  straining, 
striking  the  bandage  over  the  eye  with  the  hand  or  against  some 
object  or  the  impact  of  a  faulty  dressing.  It  is  by  some  also 
attributed  to  swelling  of  abandoned  cortex.  So  long  as  the  lips  of  the 
wound  are  closed,  and  before  they  have  actually  united  the  anterior 
chamber  is  filled  with  he  aqueous  humor,  at  which  time  compara- 
tively slight  pressure  is  sufficient  to  cause  a  parting  of  the  lips, 
when  the  aqueous  gushes  out,  carrying  the  iris  with  it.  The  patient 
is  then  often,  though  not  always,  aware  of  a  sudden  change  in  the 
feeling  of  the  eye,  and  that  organ,  from  having  been  relatively 
comfortable,  becomes  uneasy.  There  is  pain  or  a  feeling  as  if  a 
foreign  body  had  gotten  into  the  eye,  and  the  dressing  beneath  is 
found  moist  from  lacrimation.  Objection  has  often  been  made  to 
mydriasis  after  simple  extraction,  on  the  ground  that  it  favors 
prolapse  of  the  iris.  With  this  the  writer  does  not  agree.  Until 
the  anterior  chamber  reforms  the  pupil  remains  contracted. 
After  closure  of  the  wound  the  mydriasis  returns.  Now,  should 
the  wound  suddenly  reopen,  the  iris,  with  pupil  enlarged,  will 
offer  less  resistance  to  tlie  quick  outrush  of  the  acpieous  than  if 
its  pupil  were  small. 

These  are  conditions  that  demand  immediate  attention,  i.e., 
removal  of  the  bandage  and  insj^ection  of  the  eye.  If  the  iris  be 
found  in  the  wound  and  is  sufficienlly  free  to  admit  of  the  procedure, 
the  eye  is  cocainized,  the  iris  is  re])hiccd  with  the  spatula,  as  described 
a  few  ])aragraphs  back,  and  eserin  instilled  (Fig.  289).     If  this  be 


CONSECUTIVE    ACCIDENTS 


535 


impracticable  the  only  altcrnati\-c  is  lo  make  an  iridectomy,  in- 
deed, in  but  few  instances  are  we  allowed  any  other.  Now  and 
again  when  cicatrization  is  pretty  well  established,  a  small  hernia 
or  projection  of  the  iris  is  noticed,  for  which  a  searing  by  means 
of  a  small  galvanic  electrode  proves  a  most  efficient  remedy. 
A  recent  hernia  may  sometimes  be  manijjulated  with  smooth-jawed 
forceps  and  s|)atula,  till  tlioroughly  mobilized,  snip|)ed  off,  the  iris 


Fig.  289. — Slicing  movement  witli  si)atula. 


replaced,  the  opening  seared  within  the  galvanocautery,  and 
eserin  instilled;  though  myotics,  as  a  rule  are  of  little  avail. 

j\Iany  times,  undoubtedly,  this  rush  of  aqueous  is  induced  by 
something  which  takes  place  at  the  first  dressing  of  the  eye,  most 
often  by  pressure  that  is  brought  to  bear  u])on  the  lids  in  lirst 
open  ng  them,  either  by  the  physician's  thumb  or  by  the  patient's 
orbicularis  (see  After-treatment). 

H.  Beckles  Chandler,  of  Boston,  contributes  an  article  to  Knapp's 
x^rchives  for  January,  1904,  entitled,  ''Report  of  312  Cases  of  Cata- 
ract Extraction  with  a  Small  Peripheral  Buttonhole  of  the  Iris." 


536  EXTRACTION  OF  CATARACT 

This  opening  is  made  by  excising,  by  means  of  small  iris  forceps, 
whose  teeth  "are  at  the  tip  end,"  "and  scissors  whose  blades  are 
very  thin,"  a  circular  piece  of  the  iris,  one  millimeter  in  diameter 
and  "as  near  the  root  of  the  iris  as  possible."  The  corneal  section 
is  exactly  in  the  sclero-corneal  junction  and  the  buttonhole  is  made 
after  delivery  of  the  lens.  According  to  the  author,  it  serves  the 
double  purpose  of  a  sluice-gate  for  preventing  prolapse  and  of  a 
vent  through  which  to  milk  out  the  cortex  that  slips  up  behind  the 
iris.  In  the  312  extractions  reported,  there  was  iris'  prolapse  in 
but  four,  and  two  of  these  were  "  the  direct  result  of  violence." 

Peripheral  Incision  of  the  Iris.  To  quote  Elschnig  {Annals  of 
Oph.,  July,  1912.):  "The  frequency  of  iris  prolapse  stands  as  the 
most  important  hindrance  to  the  general  adoption  of  simple  cat- 
aract extraction,  i.e.,  extraction  without  iridectomy.  Numerous 
operators  have  advocated  various  methods  to  prevent  prolapse  of 
the  iris,  but  until  recently  none  of  them  seem  to  have  earned  a 
permanent  place  in  the  realms  of  operative  ophthalmology.  A 
few  years  ago  Hess  again  advocated  the  peripheral  iridectomy  which 
was  first  employed  by  Bell  Taylor  in  187 1.  Hess  {Arch.  f.  Augen- 
heilk.,  Bd.  LXVI,  S.  33,  19 10),  reported  600  such  extractions  with 
only  0.66  per  cent,  of  iris  prolapses. 

Influenced  by  these  results,  which  were  made  public  at  the 
Budapest  International  Congress  of  Medicine  in  1909,  I  com- 
menced using  the  peripheral  incision  of  the  iris  advocated  by 
Bajardi  in  1895,  and  up  to  the  15th  of  February,  1912,  had  operated 
287  eyes  by  this  method.  In  two  cases  iris  prolapse  occurred,  due, 
I  believe,  to  insufficient  incision  of  the  iris.  Even  if  these  two 
cases  had  been  considered  among  the  total  number,  the  percentage 
of  prolapses  would  be  only  0.7  per  cent.;  in  other  words,  not  more 
than  the  same  percentage  occurring  in  extraction  combined  with 
iridectomy. 

The  procedure  is  as  follows:  After  the  regular  incision  and  cap- 
sulotomy  have  been  performed,  the  conjunctival  flap  is  grasped 
with  a  forceps  and,  together  with  the  corneal  flap,  is  turned  forward. 
The  iris,  completely  exposed,  is  then  incised  close  to  the  scleral  lip 
of  the  wound  with  the  small  pointed  branch  of  a  de  Wecker  scissors 
(Esbach  scissors),  practically  raising  a  fold  of  the  iris  and  making 
an  incision  about  i  mm.  long  parallel  to  the  edge  of  the  cornea 
(Fig.  290).  In  order  not  to  mutilate  the  surface  of  the  iris  too  badly, 
the  incision  must  be  kept  well  near  the  scleral  lip  of  the  wound. 


PERIPHERAL    INCISION    OF    IRIS 


537 


for  the  incision  through  the  limbus  (comprising  one-third  to  two- 
lifths  of  the  circumference  of  the  cornea)  is  well  subconjunctival. 

Of  course,  the  iris  incision  can  be  made  immediately  upon  com- 
pleting the  corneal  section,  but  I  consider  it  better  to  carry  out  the 
more  important  capsulotomy  first  before  the  patient  has  become 
tired.  In  those  cases  that  show  the  maximal  mydriatic  effect  ^'of 
the  cocain,  even  after  the  capsulotomy,  the  iris  incision  should  be 
made  after  delivery  of  the  lens  and  reposition  of  the  iris,  for  the 
danger  of  incising  the  body  or  the  sphincter  of  the  iris  is  too  great. 
Injury  of  the  vitreous  is,  of  course,  possible,  buti^improbable  when 
proper  care  is  exercised.  ^''''' '    • 


290.- 


peripheral  incision. 


If  the  operator  has  had  no  experience  with  this  technic,  it  is 
much  safer  to  perform  the  iris  incision  with  the  lens  present.  If 
the  incision  be  too  large,  the  upper  edge  of  the  lens  may  present 
itself  herein  instead  of  in  the  pupillary  area,  as  occurs  so  frequently 
with  a  peripheral  iridectomy.  However,  this  can  be  easily  replaced 
by  light  pressure  with  the  spatula.  After  smooth  reposition  of 
the  iris  and  the  conjunctival  flap,  a  few  drops  of  eserin  are  instilled 
and  an  adhesive  plaster  bandage  applied  over  both  eyes.  On  the 
same  afternoon  the  bandage  is  loosened,  and  on  the  next  morning 
atropin  is  instilled  and  the  second  eye  left  open.     In  many  cases 


538  EXTRACTION  OF  CATARACT 

the  iris  incision  is  but  scarcely  visible  after  the  wound  has  healed. 
How  this  iris  root  incision  prevents  prolapse  is  so  simple  that  it  does 
not  need  any  explanation." 

It  has  long  been  a  mooted  question  as  to  whether  or  not  iridectomy 
really  tended  to  prevent  prolapse  and  incarceration  of  the  iris.  Panas 
reports  iris  prolapse  in  5  per  cent,  of  simple  extractions.  Becker  says 
this  accident  more  frequently  follows  the  combined  than  the  simple 
operation,  and  gives  statistics  based  on  an  anatomical  examination 
of  17  eyes  after  simple  extraction,  in  which  iris  tissue  was  found  in 
the  wound  three  times,  or  18  per  cent.,  while  in  15  eyes  examined 
after  combined  extraction  it  occurred  10  times,  or  60  per  cent. 
Kollner  reports  289  incarcerations  following  1,284  combined  extrac- 
tions in  the  clinic  of  Prof.  Michel,  of  Berlin,  i.e.,  in  22  per  cent, 
of  the  cases.  The  wide  variation  in  these  reports  may  be  accounted 
for  in  part  by  some  observers  basing  their  deductions  on  the  gross 
findings  in  the  living  subject,  while  others  resort  to  careful  examina- 
tion of  the  enucleated  eye,  as  did  Becker.  Differentiation  must 
also  be  made  between  those  cases  of  prolapse  and  incarceration 
following  the  combined  extraction  and  those  occurring  after  extrac- 
tion subsequent  to  a  preliminary  iridectomy. 

Replacement  of  the  Iris  by  Traction  from  Within  the 
Anterior  Chamber. — In  this  connection  it  is  well  to  mention  this 
manner  of  dealing  with  an  iris  prolapse,  lirst  done  by  Dr.  John 
Dunn  {Archives  of  Oph.,  Sept.,  1907).  It  is  more  applicable  to 
traumatic,  and  strangulated  prolapse,  particularly  when  situated 
inside  of  the  periphery  of  the  cornea,  than  to  that  following  iridec- 
tomy and  extraction.  An  incision,  not  over  2  mm.  in  length,  is 
made  with  the  point  of  a  Graefe  knife,  in  the  base  of  the  cornea, 
opposite  the  site  of  the  prolapse.  Through  this  is  passed  a  blunt 
iris  hook  whose  crook  is  rather  wide  open.  It  is  of  immense  advan- 
tage to  ha\e  the  manipulation  of  this  instrument  within  as  an  adjunct 
to  that  of  the  spatula  without. 

Cystoid  cicatrix  is  one  of  the  very  late  after-complications 
following  cataract  operations  and  iridectomies,  where  there  was 
healing  of  the  wound  with  the  iris  included.  A  fold  of  iris  protrudes 
in  the  form  of  a  hernia  or  a  small  sinus  leading  into  the  anterior 
chamber  remains  beneath  the  conjunctiva  where  the  iris  is  en- 
tangled, and  an  ever  increasing  sac  of  aqueous  is  the  result.  The 
first-mentioned  form  is  most  dangerous,  as  nothing  intervenes  be- 
tween the  external  world  and  the  interior  of  the  eye  but  the  attenu- 


CONSECUTIVE    ACCIDENTS 


539 


aled  and  degenerated  iris,  which  really  amounts  to  a  i)artial 
staphyloma  anterior.  Then  let  there  be  acquired  a  septic  condition 
of  the  conjunctiva  or  of  the  lacrimal  canal,  and  infection  with 
panophthalmitis  is  likely  to  occur  at  any  moment.  Besides,  the 
iris  is  drawn  more  and  more  into  it,  thus  interfering  with  vision,  and 
the  growing  vesicle  becomes  inconvenient  and  unsightly. 

The  galvanocautery,  repeated  a  number  of  times  if  necessary,  and 
a  long  continued  compression  bandage  is  the  best  remedy.  If  the 
second- mentioned  variety  is  in  question,  the  cyst  should  be  freely 
incised,  the  underlying  iistula  sought  and  well  cauterized.^  Another 
sequel  of  these  complications  is  high  or  incorrigible  astigmatism. 
Something  is  to  be  hoped  for  in  the  experimental  incisions  as  a 
remedy  for  this  defect. 

Retroversion  or  involution  of  the  iris  is  another  rare  phenom- 
enon after  extraction.  This  consists  in  a  turning  backward  of  a 
portion  or  even  all  of  the  pupillary  border.  Most  often  it  is  the 
upper  portion,  which  gives  much  the  appearance  of  a  coloboma. 
It  is  particularly  liable  to  occur  after  escape  of  vitreous  during  the 
operation.  The  shrinking  back  of  the  extruding  process  of  that 
body  pulls  the  iris  back  with  it,  or  in  some  cases  actual  connective 
tissue  bands  form,  by  which  the  iris  becomes  tied,  as  it  were,  to 
the  vitreous.  Once,  in  a  case  of  soft  cataract  where  I  had  made 
discission,  the  entire  iris  disappeared,  simulating  aniridia,  and  it 
required  several  instillations  of  eserin  solution  to  reinstate  the 
membrane. 

Iritis  and  cyclitis,  when  encountered  in  an  eye  after  cataract 
operations,  do  not  differ  materially  in  character  from  these  inflam- 
mations when  arising  from  other  causes.  Indeed,  the  same  pre- 
disposing causes  are  often  operative  in  both  instances.  Owing  to 
the  changed  relations,  however  caused  by  the  operation,  and  to 
the  absence  of  the  lens,  etc.,  these  diseases  in  aphakial  eyes  present 
phases  that  are  not  found  under  other  circumstances.  One  of  these 
concerns  the  peculiar  distortions  and  the  closure  of  the  pupil. 
The  disease  may  vary  in  severity  from  an  insignificant  localized 
inflammation  and  a  tiny  synechia  at  a  spot  where  there  has  been  a 
minute  rupture  of  the  sphincter,  of  the  pupil,  through  all  grades  of 
iritis,  synechia  posterior,  occlusion  and  closure  of  pupil,  cyclitis 
with  glaucoma,  or  general  uveitis  with  |)hlhisis  bulbi;  or  even  sym- 
pathetic ophthalmia  may  result. 

1  Berry,  Oph.  Review,  xxi,  88. 


540  EXTRACTION  OF  CATARACT 

These  processes  are  excited  by  violence  to  the  iris  and  ciliary 
body  in  some  part  of  the  operation,  by  the  iris  getting  into  the 
incision,  by  the  implantation  of  microbes,  etc.,  but  most  often, 
perhaps,  by  abandoned  lens  remains.  And  just  here,  another 
word  as  to  the  importance  of  freeing  the  eye  of  all  cortical  residue, 
as  nearly  as  possible,  at  the  proper  time  of  the  operation.  The 
most  experienced  and  observant  ophthalmic  surgeons  all  agree  as  to 
their  pernicious  effects  when  left  in  any  quantity.  In  attempting, 
therefore,  a  simple  extraction,  when  one  is  convinced  that  certain 
otherwise  inaccessible  cortex  lurks  behind  the  upper  portion  of  the 
iris,  an  iridectomy  it  imperative.  The  most  treacherous,  of  course, 
are  the  transparent  remains  that  do  not  show  any  opacity  until  a 
day  or  two  after  the  operation,  as,  for  example,  those  from  the  nuclear 
cataract,  that  will  cling  to  the  capsule,  especially  the  posterior  half 
and  elude  the  best  directed  effort.  Then,  by  their  swelling,  crowd- 
ing, etc.,  start  the  mournful  train  of  symptoms  that  so  often  prove 
the  bane  of  the  operator  and  the  undoing  of  the  eye. 

The  treatment  that  is  best  for  these  same  affections  in  general 
is  also  best  for  these.  Locally,  atropin,  hot  applications,  leeches 
to  the  temple,  subconjunctival  injections  of  salt  or  mercurial 
solution,  etc.  Internally,  calomel,  salicylates,  pilocarpin  hypo- 
dermics, etc.,  and  attention  to  any  predisposing  dyscrasy.  If  there 
is  any  amount  of  lens  matter  in  the  eye,  it  should  be  seen  to  that  the 
pupil  does  not  contract,  if  it  is  in  the  power  of  atropin  or  any  other 
mydriatic  to  prevent  it.  A  considerable  quantity  of  fluffy  or 
flocculent  lens  remains  is  well  tolerated  by  the  eye  and  is  not  to  be 
feared. 

Infection— suppuration— "pus-wound"  of  the  Germans- 
may  be  either  endogenous  or  exogenous,  and  the  exogenous  infection 
may  primarily  involve  either  the  corneal  incision  or  the  anterior 
chamber  or  both.  Under  prevailing  methods  and  with  favorable 
surroundings,  this  dreadful  contingency  is  infrequent.  A  surgeon 
may  now  make  two  or  three  hundred  consecutive  extractions  without 
once  encountering  it.  Yet,  again,  it  may  be  his  fate  to  have  it  occur 
in  several  cases  in  quick  succession.  With  properly  prepared 
patient  and  paraphernalia  and  with  a  normal  tear  canal  and  con- 
junctiva, the  source  of  the  infection  is  always  a  mystery,  and  we 
may  thank  our  stars  that  we  arc  so  often  s])ared  the  unforeseen  evil. 
Anatomical  and  bacteriological  examination  have  shown  that  grave 
forms  of  endogenous  infection  may  be  due  to  capillary  microbian 


CONSECUTIVE    ACCIDENTS  54I 

embolism  of  the  vessels  of  the  retina  and  choroid  and  that  these 
may  contain  the  same  bacteria  that  have  produced  a  general  infec- 
tion. Surgical  interference  seems,  under  these  circumstances,  to 
render  susceptible  to  infection  eyes  that  otherwise  would  be  immune. 

Owing  to  the  nature  of  the  poisoning  agent,  or  to  the  treatment 
instituted,  or,  it  may  be,  to  the  qualities  existing  in  the  eye  or  the 
system,  the  suppuration  will  be  of  every  grade  from  that  which  will 
terminate  with  slight  sloughing  of  the  lips  of  the  wound,  leaving 
merely  a  broad  cicatrix,  on  through  a  mxiddle  grade,  affecting  all  the 
structures  anterior  to  the  ciliary  body,  to  that  so  overwhelming  in  its 
virulence  as  to  practically  destroy  the  eye  in  a  single  night.  It 
seems  that  vitreous  humor  in  the  wound  is,  of  all  things,  the  most 
inviting  to  pygenic  bacteria. 

If  present,  the  trouble  usually  begins  within  twenty-four  hours, 
and  hardly  ever  beyond  seventy-two  hours  from  the  time  of  operating. 
Bach  says  that  infections  appearing  earlier  than  forty-eight  hours 
after  the  operation  come  from  the  instruments.  Dor  states  that  in- 
fections coming  after  forty-eight  hours  and  before  seventy-two 
hours  are  from  the  conjunctiva  and  not  from  the  instruments. 
Most  infections  occurring  after  four  days  are  probably  endogenous. 
At  the  onset  of  the  infection  generally,  not  invariably,  there  is  pain, 
lacrimation,  etc.  Inspection  of  the  eye  shows  puffiness  of  the  lids, 
edema  of  the  conjunctiva,  mucous  or  mucopurulent  discharge, 
gray  softening  of  the  lips  of  the  incision,  and,  if  the  process  has  got 
well  under  way,  yellowish  streaks  leading  from  the  wound  into  the 
deeper  parts  of  the  globe,  and  a  turbid,  greenish  glimmer  of  the  iris. 
A  rarer  form  of  infection  is  that  which  originates  in  the  iris  or  vitreous, 
and  comes  somewhat  later  than  wound  suppuration;  indeed,  before 
its  onset"  healing  of  the  incision  has  generally  been  effected.  The 
origin  of  the  poison  in  these  cases  is  behaved  usually  to  be  endogen- 
ous. In  spite  of  the  most  vigorous  measures,  the  usual  end  of  a  rank 
infection  is  panophthalmitis.  Now  and  then,  by  the  very  early 
recourse  to  energetic  treatment,  however,  not  only  is  the  globe 
saved,  but  useful  sight  as  well.  As  our  science  advances,  the  aspect 
of  these  cases  grows  less  discouraging,  just  as  their  occurrence 
becomes  less  frequent,  and  one  is  not  expected  to  give  up,  as  formerly, 
but,  on  the  contrary,  to  make  a  desperate  fight  for  it  in  every  instance. 

For  the  prevention  of  infective  processes  after  operations  that 
necessitate  opening  of  the  globe,  l)e  Wecker  conceived  the  idea 
of  making  peritomy,  loosening  up  the  conjunctiva  and  putting  in  a 


542  EXTRACTION  OF  CATARACT 

purse-String  suture,  making  the  extraction  (or  other  operation), 
then  drawing  the  conjunctiva  together,  thus  covering  with  it  the 
entire  cornea.  This  procedure  has  been  practised  lately  by  Ellet, 
of  Memphis.  Kuhnt,  of  Konigsberg,  for  the  same  purpose, 
loosened  the  conjunctiva  only  around  the  upper  half  or  two-thirds 
of  the  cornea,  drew  it  down  and  sutured  it  to  the  episcleral  tissue  at 
either  side  opposite  the  center  of  the  cornea.  Gifford,  of  Omaha, 
makes  use  of  the  purse-string  suture  surrounding  the  entire  cornea 
and  ending  below,  but  dissects  up  only  that  encircling  the  upper 
half.  After  the  cataract  operation,  he  ties  the  suture  which  i)ulls 
the  conjunctiva  effectually  over  the  incision. 

Aside  from  the  preventive  measures  already  enumerated,  mention 
must  be  made  of  the  internal  administration  of  potassium  iodid. 
L.  Dor,  before  the  French  Congress  of  Ophthalmology  of  1901, 
reported  experiments  upon  animals  whereby  he  had  demonstrated 
that  one  to  two  grams  of  potassium  iodid  given  the  day  before 
the  operation  had  power  to  prevent  all  inflammatory  phenomena 
in  eyes  inoculated  with  cultures  of  the  staphylococcus  pyogenes 
aureus  in  doses  sufficient  to  produce  panophthalmitis  in  the  eyes  of 
control  animals.  Certainly,  a  simple  and  harmless  prophylactic 
which  could  easily  be  added  to  the  routine  of  preparation. 

Treatment. ^ — Calomel,  salicylates,  milk-punches,  quinine  and 
strychnin,  leeches  to  the  temple.  Locally,  the  hourly  (night  and 
day)  moderate  irrigations  of  very  hot  1/2000  or  i/iooo  bichlorid 
solution,  immediately  followed  by  copious  ones  of  hot  boric  acid 
solution.  Subconjunctival  injections  of  the  salts  of  mercury  and 
the  injection  of  antiseptics  into  the  anterior  chamber,  etc.  I  have 
recently  seen  such  an  eye  apparently  saved  by  the  deep  (subtenon- 
ian)  injection  of  the  cyanid  of  mercury  i/iooo,  8  to  12  minims  at  a 
time,  every  twenty-four  or  forty-eight  hours.  Cautery  of  the  in- 
cision is  practised  by  some  after  reopening  it.  This  is  followed  by 
irrigation  of  the  anterior  chamber  with  mild  antiseptic  solutions. 
French  surgeons  are  partial  to  the  use  of  methylene  blue,  both 
internally  and  externally,  in  these  infections,  but  the  practice  has 
never  been  po])ular  in  the  United  States.  Haab  introduces  into  the 
anterior  cham])er  soluble  rods  impregnated  with  iodoform. 

Filtration  Chemosis. — In  those  cases  where  the  corneal  fla])  has 
included  some  i)ortion  of  the  conjunctiva,  the  incision  in  the  latter 
occasionally  unites  firmly  before  there  is  healing  of  that  in  the 
underlying  cornea,  hence,  if  the  acjueous  now  csca])es,  it  will  ac- 


C()NSi:ClTTIVE    ACCIDENTS  543 

cumulate  between  the  sclera  and  the  conjunctiva.  The  opalescent, 
edematous  swelling  which  results,  is  of  unmistakable  appearance — 
being  free  from  redness,  and  changing  its  location  in  obedience  to 
the  law  of  gravity.  The  progress  of  the  eye  is  not  seriously  inter- 
fered with,  and  no  s])ecial  intervention  is  called  for. 

Iritis,  cyclitis,  and  glaucoma,  secondary  to  the  extraction,  have 
already  been  considered  (see  p.  539). 

Late  Wound  Healing. — This  phenomenon  is  recognized  by 
the  persistent  or  intermittent  absence  of  the  anterior  chamber  for 
several  days,  or  even  weeks,  after  the  operation.  The  delayed 
union  is  most  likely  the  result  of  shreds  of  capsule  or  iris,  particles  of 
the  lens,  clots  of  blood,  or  portions  of  vitreous  that  lie  in  the  cut  and 
prevent  union,  or  of  undue  pressure  upon  the  globe  from  an  improper 
dressing,  and  too  tight  a  bandage.  It  has  been  thought  by  many  to 
be  one  of  the  causes  of  secondary  glaucoma^  through  entrance  of  the 
corneal  epithelium  into  the  anterior  chamber,  and  there  piling  up 
in  the  angle  of  the  iris;  and  by  causing  adhesions  between  iris  and 
cornea,  etc.  It  also  leads  to  the  grooving  or  guttering  of  the  wound. 
When  discovered  the  danger  from  suppuration  is  usually  passed,  the 
thing  needful  being  to  keep  both  eyes  carefully  bandaged,  to  enjoin 
quiet  and  rest,  to  prevent  prolapse  of  the  iris,  and,  in  most  cases  all 
will  be  well.  The  least  movement  of  the  globe  causes  a  "working" 
of  the  iris  toward  the  incision,  and  a  crowding  against  the  tra- 
beculum, or  blocking  of  the  iridic  angle.  When  iridectomy  has  ac- 
companied the  extraction,  this  working  of  the  iris  results  in  the 
swollowing  up  of  the  pillars  of  the  coloboma  by  the  inner  lips  of  the 
corneal  wound,  and  in  adhesions  between  iris  and  cornea. 

The  eye  should  be  carefully  inspected  with  a  view  to  the  possible 
discovery  of  the  cause  and  the  removal  of  the  non-healing  element. 
If  no  obstruction  is  detected  and  the  leakage  persists,  a  spatula  may 
be  passed  through  the  wound  with  a  slicing  motion,  provided  the 
union  has  not  progressed  too  far,  and  the  eye  copiously  douched 
with  warm  boric  solution.  Iridectomy  has  often  been  resorted  to 
with  the  eiTect  of  causing  immediate  closure.  Just  how  this  acts,  I 
am  not  prepared  to  explain.  Arlt  thought  that  the  constant  outflow 
of  aqueous  in  delayed  union  was  a  means  of  preventing  suppuration, 
and  rather  welcomed  the  accident,  as  have  others  since. 

Gifford,  of  Omaha,  as  soon  as  he  discovers  that  the  anterior 
chamber  is  empty,  leaves  off  the  bandage,   the  usual  effect  being 

1  Metier,  v.  Graefe's  Arch.,  Hi  3,  and  Ophth.  Review,  Nov.,  iqoi. 


544  EXTRACTION  OF  CATARACT 

prom])t  closure  of  the  wound.  A  badly  constructed  pad  over  the 
eve,  or  an  irregularly  constricting  bandage  may  not  only  retard 
union,  but  may  cause  the  freshly  healed  incision  to  reopen,  therefore 
GilTord's  procedure  is  perfectly  logical. 

Striated  Cornea,  or  as  it  has  also  been  named,  striped  keratitis 
(Heymann),  though  it  can  hardly  be  called  an  inflammation,  refers 
to  a  singular  appearance  presented  by  the  cornea  (noticeable  at  the 
first  dressing)  after  certain  extractions  through  an  inadequate 
incision  and  one  whose  summit  was  rather  far  within  the  limbus. 
The  distinguishing  feature  is  a  great  number  of  line  gray  lines— a 
true  striation — extending  downward  varying  distances  from  the 
cut.  They  have  been  thought  by  C.  Hess  to  be  wrinkles  in  the 
posterior  layers  of  the  cornea  due  to  the  stretching  and  rubbing  of 
the  flap  incident  to  the  violent  delivery  of  the  cataract.  De  Wecker 
considered  the  appearance  to  be  the  result  of  simple  retention  of 
the  lymph  in  the  channels  adjacent  to  the  wound  due  to  traumatism 
and  not  to  imbibition  of  liquid  or  infiltration.  He  looked  upon  it 
as  a  quite  innocent  condition,  exceping  in  the  event  of  an  accompany- 
ing violent  iris  reaction,  when  the  vertical  striae  are  seen  to  be  crossed 
by  a  horizontal  set.  If  all  eyes  upon  which  extraction  has  been 
made' were  closely  scrutinized  with  a  magnifying  glass  under  strong 
focal  illumination,  this  condition  would,  to  a  degree,  doubtless  be 
found  in  a  large  number.  The  treatment  consists  only  in  ordinary 
care  and  bandaging.     Dionin  is  usually  indicated. 

Glaucoma,  secondary  to  the  operation,  is  not  a  frequent  sequel, 
but  is  said  to  follow  in  i%  after  the  combined  operation,  and  less 
often  after  the  simple.  Aside  from  predisposition  to  the  disease, 
among  the  local  exciting  causes  are  abuse  of  atropin,  abandoned 
lens  remains,  incarceration  of  iris  or  of  the  capsule,  rudeness  in 
delivering  lens  or  in  the  capsulotomy,  or  anything  that  tends  to  the 
excitation  of  uveitis.  Delayed  union  of  the  wound  has  been  set 
down  as  a  factor  for  the  reasons  alluded  to  under  that  head. 

However,  one  should  not  always  look  to  the  eye  alone  for  the 
cause  of  the  glaucoma.  There  are  times  when  the  disease  is  un- 
doubtedly due  to  a  more  remote  systemic  condition.  This  may 
be  some  kind  of  autointoxication,  as  from  renal  insufficiency;  or  it 
may  be  a  form  of  discrasy,  like  gout  or  syphilis.  According  to 
De  Lapersonne,  uric  acid  retention  tends  to  excite  glaucoma  by  the 
production  of  a  s[)ecies  of  edema  of  the  vitreous.  These  facts  serve 
to  empliasi/.c  ihe  im|)()rlance  of  a  thorough  ])hysical  examination 


CONSECUTIVE    ACCIDENTS  545 

in  connection  with  the  operation  of  extraction.  Jn  tiiis  way  one  may 
at  times  be  greatly  aided  in  the  choice  of  a  remedy  with  which  to 
combat  a  complication — be  enabled,  for  example,  to  cut  short  an 
attack  of  glaucoma  by  measures  other  than  surgical. 

The  combined  operation,  because  of  the  frequent  involvement 
of  some  part  of  the  iris  in  the  healing  of  the  incision,  is  thought 
to  favor  glaucoma  more  than  is  the  simple.  When  the  tension  is 
obviously  due  to  swelling  cortex  behind  the  iris  after  simple  extrac- 
tion, iridectomy  should  be  immediately  resorted  to  and  whatever 
is  feasible  of  the  offending  material  removed.  In  the  great  majority 
of  instances,  however,  the  cortex  will  have  become  encapsuled  or 
so  adherent  that  its  attempted  riddance  is  out  of  the  question.  In 
some  of  the  milder  forms  the  process  can  be  stopped  by  the  use  of 
pilocarpin  or  eserin,  but  prompt  iridectomy  or  anterior  sclerotomy 
( aracentesis)  will  be  required  in  all  the  others. 

Postoperative  lunacy,  senile  dementia,  delirium  loquace, 
etc.,  are  various  names  that  refer  to  a  mental  disorder  that  is  not 
uncommon  after  the  extraction  of  senile  cataract.  The  degree 
varies  from  slight  confusion  of  thought  and  incoherence  of  speech  to 
violent  maniacal  frenzy.  The  predominant  idea  throughout  is  that 
of  having  been  deserted,  left  in  darkness  or  among  strangers  when 
in  dire  distress — a  state  akin  to  what  is  known  as  nostalgia.  The 
sufferer  wants  to  go  home  and  continually  calls  for  those  nearest  or 
dearest.  He  w-ants  to  flee  from  his  persecutors,  and  herein  lies  the 
greatest  danger.  It  is  not  to  the  lame  eye — indeed,  it  is  astonishing 
how  seldom  aught  injurious  ever  comes  to  it — but  it  is  the  life  and 
limb  of  the  patient.  Thought  or  conceit  of  that  organ  does  not  enter 
into  his  plight.  He  wants  to  get  away  and,  in  the  severe  cases,  he 
goes,  and  if  not  restrained,  in  seeking  an  exit,  he  tries  to  scale  the 
walls,  to  climb  the  door,  to  throw  himself  out  of  the  window,  or  over 
the  railing  of  the  stairs.  So  that  the  list  of  fatal  casualities  from  this 
cause  is  nothing  short  of  appalling. 

The  subject  was  fully  discussed  at  the  1903  meeting  of  the 
American  Ophthalmologic  Society,  as  the  result  of  an  admirable 
paper  then  read  by  Kipp,  of  New^ark,  N.  J.,  and  published  in 
Knapp's  Archives,  July  19,  1903.  In  the  January,  1904,  number 
of  Knapp's  Archives,  C.  E.  Finlay,  of  Havana,  Cuba,  calls  attention 
to  a  paper  by  C.  Fromaget,  of  Bordeaux  in  the  Annales  d' occults tique, 
cxxiii,  p.  183,  in  w^hich  "he  considers  the  delirium  following  eye 
operations  the  result  of  an  autointoxication,  most  often  uremic, 
35 


546  EXTRACTION  OF  CATARACT 

and  due  to  the  accumulation  in  the  system  of  certain  excrementi- 
tious  products  brought  about  by  some  renal  insufficiency,  and  which 
is  made  patent  by  a  diminution  in  the  amount  of  urine,  in  its  specific 
gravity  or  in  the  proportion  of  urea."  Dr.  Finlay  cites  a  case  of 
his  own  in  support  of  Fromaget's  theory. 

Whatever  else  may  contribute  to  this  ailment— the  toxic  effect  of 
mydriatics  or  what  not— it  is  certain  that  confinement  in  a  strange 
place  and  darkness  are  very  largely  responsible;  the  bandaging  of 
both  eyes,  total  darkness  in  the  room,  etc.  For  the  same  reasons, 
there  are  many  individuals,  both  old  and  young,  who  are  unable  to 
sleep  where,  on  awaking  in  the  night,  they  cannot  see  a  light.  Be 
the  latter  ever  so  faint,  it  answers  the  purpose. 

Kipp  advocates  that,  where  the  distance  is  not  inconvenient,  the 
patient  be  taken  home  in  order  that  he  may  recover  his  faculties. 
The  next  best  thing  is  to  have  a  member  of  his  famiy  come  to  him 
and  coax  him  back  to  reason;  or,  if  this  cannot  be  done,  the  soothing 
must  be  left  to  those  in  attendance.  Bromids  and  chloral  are 
sometimes  of  avail,  though  it  is  often  impossible  to  induce  the 
patient  to  swallow  anything.  The  well  eye,  if  there  be  one,  and 
it  is  occluded,  should  be  uncovered  at  the  first  signs  of  the  dis- 
turbance, and  the  patient  must  be  watched  and  guarded  without  an 
instant's  intermission.  Knapp,  in  De  Schweinitz's,  "  Diseases  of  the 
Eye,"  commends  hypodermic  injections  of  hyoscin  (hydrobromate), 
gr.  T   ICO  pro  dosi,  to  control  the  mania. 

Atropin  Dermatitis.^ — The  well-known  idiosyncrasy  whereby 
the  local  use  of  atropin  or  kindred  drugs  causes  a  peculiar,  nasty, 
greasy  swelling  and  inflammation  of  the  skin  of  the  lids,  must  be 
watched  for  and,  if  shown,  another  mydriatic,  such  as  duboisin  or 
hyoscin,  substituted.  Usually  this  suffices,  though  rarely  each  one 
has  the  same  effect  and  must  all  be  abandoned. 

Hyphema,  or  hemorrhage  in  the  anterior  chamber,  which  is  an 
occasional  occurrence,  is  more  often  noted  after  the  combined,  than 
after  the  simple  extraction,  and  was  especially  frequent  after  the 
Graefc  modified  linear.  The  predisposing  cause  is  hyperemia 
of  the  iris,  and  the  exciting  one  either  a  blow  or  a  strain,  or  it  means 
a  threatened  iritis.  In  the  latter  event,  it  is  an  indication  for 
atropin,  salicylates,  etc. 

Spastic  or  senile  entropion  of  the  lower  lid,  induced  by  band- 
aging, is  a  condition  much  to  ])e  a])prehended  after  extraction. 
Eyes  ha\'e  been  lost  through  want  of  timely  observance  of  it.     If 


COMBINED    METHOD  547 

the  lower  lid  shows  the  slightest  tendency  to  roll  in,  measures,  such 
as  strapping  it  down  to  the  cheek  with  collodioni/.ed  guuze  or  slrii)> 
of  rubber  adhesive  plaster  or  the  pulling  in  of  an  Aril  suture,  must 
be  taken  at  once. 

Kianopia,  kianopsia,  blavinopsia,  or  blue  vision,  is  a  very 
common  accompaniment  of  the  early  attempts  of  an  eye  to  see  after 
the  extraction  from  it  of  a  senile  cataract — nuclear  cataract  in 
particular.  Becker  thought  that  it  is  due  to  the  diffusion  of  light 
by  thin  layers  of  cortex  and  that  tlie  disappearance  of  it  was  the 
result  of  the  absorption  of  the  latter. 

The  more  commonly  accepted  explanation  of  the  phenomenon  is 
that  the  light,  entering  the  eye,  has  for  a  long  time  been  I'dtered 
through  a  yellow  medium — the  amber-colored  lens;  and  when, 
upon  removal  of  this,  wdiite  light  is  again  admitted,  it  is  the  com- 
plement of  the  yellowy  or  the  strongly  contrasting  blue,  that  pre- 
vails until  the  eye  becomes  accustomed  to  the  change.  The  ])he- 
nomenon  soon  disappears. 

Erythropsia,  or  red  vision,  is  declared  by  some  observers  to  be 
more  common  after  extraction  of  senile  cataract  than  blue  vision. 
Such  has  not  been  my  experience.  Fuchs  accounts  for  it  in  this 
connection,  as  follows:  the  aphakic  eye  is  more  disposed  to  it  be- 
cause the  lens  has  fluorescent  properties  and,  moreover,  in  old 
people,  is  yellow.  It,  therefore,  while  present,  prevents  the 
entrance  into  the  eye  of  great  numbers  of  the  rays  of  short  vibrations 
at  the  violet  end  of  the  spectrum,  and  its  absence,  allowing  the  free 
entrance  of  these,  soon  causes,  in  these  eyes  long  unused  to  such  light, 
exhaustion  of  the  retina,  like  snow-blindness. 


SIMPLE   PERIPHERAL   CORNEAL  FLAP   EXTRACTION 
COMBINED  WITH  IRIDECTOMY. 

In  discussions  of  the  relative  merits  of  the  sim])le  and  the  com- 
bined operations  for  the  extraction  of  cataract,  the  decision  of  the 
argument  is  supposed  to  rest  upon  one's  answer  to  the  question, 
"If  your  own  eye  were  to  be  operated  upon,  which  method  would 
you  choose?"  My  reply  would  be,  "  It  would  depend  u])on  the  kind 
or  stage  of  the  cataract  and  upon  what  surgeon  was  called  lo  make 
the  operation." 

The  ultimate  success  of  the  operation  of  extraction  does  not 
depend  so  much  upon  the   particular   mode  that  is  adoi)ted  of  the 


-48  EXTRACTION    OF    CATARACT 

several  in  vogue,  as  might  at  a  glance  be  supposed.  It  is  a  question, 
largely  of  personal  equation.  Ophthalmic  surgeons  characterized 
by  the  greatest  ajjtitude  in  this  most  exacting  of  operations,  as,  for 
examj)le,  Knapp,  with  a  record  of  four  thousand  extractions,  most 
all  prefer  the  simple  method.  They  may  have  had  their  periods  of 
disaffection  in  regard  to  it,  but  they  have  ended  by  coming  back  to  it 
in  nearly  every  instance.  Indeed,  I  doubt  not,  were  the  originators 
of  iridectomy,  in  connection  with  extraction,  alive  to-day  in  this 
era  of  antiseptic  surgery,  they  would  be  among  the  strongest  ad- 
vocates of  the  simple  extraction.  For  it  must  be  remembered  that 
V.  Graefe,  with  the  small  iridectomy  he  made  in  conjunction  with 
his  postcorneal  linear  section,  and  Jacobson,  who  a  year  or  two  later 
operated  downward  with  a  very  broad  iridectomy,  both  sought  by 
means  of  the  coloboma  not  to  avoid  iris  complications  or  to  favor 
the  removal  of  lens  remains,  but  to  lessen  the  chances  of  suppuration 
and  panophthalm His. 

In  skillful  hands  the  simple  operation  is  the  safer  and  better  in 
every  way.  If,  on  the  other  hand,  the  operator  is  wanting  in 
experience  or  is  not  sure  of  his  technic,  then,  perhaps,  in  the  in- 
terests of  all  concerned,  his  choice  should  be  for  the  combined  or, 
better  still,  for  extraction  after  a  preliminary  iridectomy.  The 
writer's  observation  and  experience  confirm  him  in  the  belief  that, 
all  things  else  being  equal,  there  are  fewer  accidents  both  during  and 
after  the  operation  of  simple  extraction,  and  that  when  these  do 
occur,  they  can  be  better  dealt  with.  Elschnig  says:  "In  the  ex- 
traction of  senile  cataract,  the  omission  of  the  iridectomy  and  the 
preservation  of  the  round  pupil  are  to  be  desired,  both  from  theoretic 
considerations  and  from  practical  experience.  As  is  well  known, 
when  the  eye  is  not  perfectly  adjusted  optically,  the  circles  of  diffu- 
sion on  the  retina  are  proportionate  to  the  size  of  the  pupil.  Con- 
sequently, under  these  cu-cumstances  of  imperfect  adjustment,  the 
smaller  the  pupil  the  sharper  the  image.  With  a  round  pupil  there 
are  no  dazzling  phenomena  in  a  strong  light,  and  the  injurious  effects 
of  the  ultra-violet  rays,  which  have  been  so  recently  studied,  arc 
avoided.  Of  course,  in  a  normal  eye  these  rays  are  absorbed  by 
the  lens.  Moreover,  the  eye  can  protect  the  retina  against  a  sudden 
excess  of  strong  light  only  if  the  pupil  is  round. 

The  practical  experiences  coincide  fully  with  the  theoretic  consid- 
erations. I  have  never  seen  crythropsia,  which  occurs  so  frequently, 
ap])ear  in  a  ])aticnl  where  the  cataract  was  extracted  with  a  round 


INDICATIONS    FOR    IRIDECTOMY  549 

pupil;  while  vision  is  unquestionably  better,  and  the  visual  power  is 
less  sensitive  toward  defects  in  the  correcting  glass  (decentration, 
oblique  position,  insufl'icient  correction,  etc.):  I  have  repeatedly 
observed  intelligent  patients  who  required  only  a  spherical  lens  for 
distance  correction,  use  this  glass  for  reading  fine  print  by  merely 
increasing  the  distance  of  the  glass  from  the  eye.  The  range  of  the 
so-called  pseudo-accommodation  is  vastly  increased  by  a  round  pupil 
because  it  eliminates  the  circles  of  diffusion.  In  addition  to  the 
optic  advantages,  the  cosmetic  results  of  a  round  pupil  cannot  be 
too  highly  valued." 

Nevertheless,  iridectomy  in  relation  to  operations  for  cataract 
has,  and  will  ever  retain,  an  important  place,  whether  it  precedes  the 
extraction  by  a  certain  period  or  is  coincident  with  it. 

Indications  for  the  Combined  Operation.— Among  the 
cataracts  that  require  it  may  be  mentioned  those  whose  capsules  are 
adherent  to  the  iris,  unripe  cataracts,  or  those  having  a  quantity 
of  soft,  transparent  cortex,  diabetic  cataracts,  and  those  attended  by 
a  rigid  pupil,  or  one  irresponsive  to  mydriatics;  as  also  the  luxated 
and  tremulous  cataracts.  These  indications,  it  may  be  added,  arc 
not  always  apparent  when  the  exigencies  of  the  operation  are  being 
discussed.  Hence,  in  preparing  the  instruments  for  any  cataract 
operation  where  iridectomy  has  not  already  been  performed,  the 
iris  scissors  and  forceps  must  never  be  omitted. 

As  to  the  kind  of  iridectomy,  there  are  a  number  of  opinions  and 
practices.  A  few  years  back,  the  majority  of  operators  made 
what  is  called  the  "keyhole"  coloboma,  requiring  for  its  proper 
fashioning,  three  snips  of  the  scissors.  The  first,  straight  from  the 
pupillary  border  to  the  periphery  of  the  iris;  the  second,  along 
the  periphery  to  form  the  base  of  the  coloboma,  and  the  third,  from 
the  latter,  straight  back  to  the  pupil  again.  This  form  is  now  more 
specifically  identified  with  iridectomy  for  glaucoma,  for  which  it  is 
the  most  effective.  Recently  the  prevailing  choice,  excepting, 
of  course,  in  those  cases  complicated  by  glaucoma,  is  for  the  one- 
snip  section,  such  as  has  been  for  a  long  time  the  kind  made  for 
optic  coloboma.  It  obviates  as  effectually  the  difficulties  of  the 
extraction  and  more  effectually  some  of  the  dangers.  It  is  simpler 
and  quicker  in  the  performance,  less  painful,  causes  less  deformity, 
and  its  coloboma,  being  free  from  the  long,  flabby  pillars,  with  their 
sharp  corners  that  characterize  the  keyhole  pupil,  the  risks  of  pro- 
lapse and  incarceration  of  the  iris  are  not  so  great. 


550  EXTRACTION  OF  CATARACT 

The  size  of  the  piece  of  iris  excised  need  not,  as  a  rule,  be  large. 
All  that  is  requistitc,  usually,  is  the  resection  of  a  small  bit  of  the 
sphincter  alone,  but  its  exact  dimensions  must  be  left  to  the  judg- 
ment of  the  operator.  As  to  the  manner  of  procedure,  it  does 
not  differ  materially  from  that  of  the  same  operation  made  for 
other  purposes  (see  chapter  on  Optic  Iridectomy).  When  one 
expects  before  making  the  corneal  incision  to  cut  the  iris  also, 
leaving  of  a  conjunctival  l^ap  is  not  so  imperative,  though  it  is 
desirable  in  any  event. 

The  idea  of  making  the  iridectomy  some  weeks  previous  to  the 
extraction,  occurred  first  to  Mooren,  of  Berlin,  in  1862.  He 
applied  it  to  all  the  cases  of  cataract  that  seemed  to  demand  iridec- 
tomy, whereas  we  of  to-day  limit  it  to  those  only  where  the  com- 
bined operation  seems  inexpedient,  such  as  the  beginning  of  progress- 
ive cataract  in  feeble  subjects  and  in  eyes  characterized  by  posterior 
synechia  and  glaucoma.  It  is  also  applicable  to  most  of  those 
enumerated  as  suitable  for  the  combined  operation.  The  same 
methods  are  pursued,  excepting,  of  course,  that  the  incision  is 
made  with  the  lance  instead  of  the  Graefe  knife.  The  shape  and 
extent  of  the  coloboma  are  regulated  as  in  the  combined  extraction. 
Be  it  understood,  however,  that  in  a  case  of  glaucoma  associated  with 
cataract,  a  long  postscleral  section  and  a  broad  peripheral  pre- 
liminary iridectomy  are  de  rigueur. 

The  writer  has  had  no  experience  with  buttonholing  the  iris,  as 
practised  by  a  few  opthalmic  surgeons  and  which  is  treated  of  in 
the  chapter  on  Accidents  Consecutive  to  Extraction.  This  consists 
in  picking  up  a  small  fold  midway  of  the  iris  zone  and  cutting  out 
a  tiny  ellipse.  The  idea  is  that  this  hole  shall  form  a  sluice  gate, 
as  it  were,  for  the  aqueous  in  case  of  after-opening  of  the  incision, 
thereby  preventing  prolapse  or  impalement  of  the  iris. 

Variations  of  Technic. — The  different  steps  of  the  operation  for 
cataract  extraction  with  the  corneal  flap,  as  described  in  a  previous 
chapter,  are  by  no  means  constant,  but  are  subject  to  many  modifica- 
tions and  changes,  according  either  to  the  peculiarities  of  the  case,  or 
to  the  views  of  individual  operators.  It  is  the  purpose  of  this  section, 
therefore,  to  cite  some  of  the  changes  in,  or  departures  from,  preva- 
lent methods,  or,  rather,  from  the  methods  already  described. 

Holding  the  Lids  Apart.— Some  surgeons  prefer  to  operate  for 
cataract  without  the  blepharostat,  instead,  having  an  assistant  per- 
form this  ser\ice  with  his  fingers  or  with  the  Desmarres  retractors. 


FLXATIOX    OF    THK    GLOBE 


551 


The  lingers  alone  are  unreliable,  especially  in  the  event  of  a  squeez- 
ing subject.  The  retractors,  or  at  least  one  retractor  for  the  ui)jjer 
lid,  is  a  safe  and  eUeclive  means  of  holding  the  lids.  A  new  and 
highly  efticient  retractor  is  that  devised  by  Fisher,  of  Chicago. 
Shown  in  Fig.  291.  Its  handle  is  of  spring  steel,  and  lies  over  the 
frontal  bone.  Thus  both  the  handle  of  the 
instrument  and  the  hand  that  holds  it  are 
out  of  the  way  of  the  operator. 

Fixation  of  the  Globe. — One  may  employ 
a  fixation  forceps  provided  with  a  locking 
device,  but  this  does  not  conform  to  the  later 
and  more  approved  ideas.  Many  unpleasant 
accidents  have  occurred  as  a  result  of  the 
lock,  for  it  is  apt  to  prove  stubborn  in  an  emer- 
gency, and  is,  on  the  whole,  best  dispensed 
with.  An  excellent  method  of  fixation,  and 
one  peculiarly  adapted  to  use  in  connection 
with  deeply  set  eyes,  is  that  of  Czermak. 
This  consists  in  grasping  the  tissue  at  the 
middle  of  the  inferonasal  quadrant  of  the 
corneal  limbus,  in  lieu  of  that  situated  imme- 
diately below.  By  this  mode  the  leverage 
exerted  upon  the  globe  by  the  knife,  in  be- 
ginning the  incision,  is  o\ercome.  Besides, 
the  handling  of  the  forceps  is  not  interfered 
with  by  contact  with  the  lower  lid-holder  of 
the  blepharostat. 

Angelucci's  Fixation.— Angelucci,  of 
Palermo,  has  gi\en  us  a  procedure  that  was 
truly  an  inspiration  on  the  part  of  its  eminent 
originator.  This  is  to  rotate  the  globe  far 
downward  and  to  seize,  with  strong  fixation 
forceps,  the  tendon  of  the  superior  rectus. 
In  this  way  not  only  is  the  eye  perfectly  steadied,  but  the  upper  lid 
is  held  out  of  the  way.  Moreover,  squeezing  and  attempts  to  roll 
the  globe  upward,  on  the  part  of  the  patient,  are  done  away  with, 
there  is  no  tendency  toward  gaping  of  the  wound,  and  the  eye  can 
be  closed  on  the  instant  when  this  is  needful.  This  method  is 
further  treated  of  under  modified  forms  of  extraction.  The  other 
recti  tendons  may  be  similarlv  utilized. 


552  EXTRACTION  OF  CATARACT 

Making  the  incision  or  corneal  section.  This  lies  either  exactly 
in  the  apparent  sclcro-corneal  junction  throughout  (with  or  without 
the  conjunctival  flap)  or  in  this  position  for  the  lower  two-thirds 
of  its  course  and  is  turned  forward  for  the  last  third,  ending  a  line 
or  two  short  of  the  upper  limbus.  Or  the  same  form  and  direction 
may  be  adhered  to,  while  the  position  is  just  forward  of  the  junction. 
The  extent  of  the  incision  varies  somewhat  with  every  operator — 
at  one  time  through  mere  accident  and  at  another  because  of  a 
definite  object  to  be  attained,  as,  for  example,  when  the  lens  is 
thought  to  be  large  and  firm,  or  vice  versa.  Rarely  does  it  include 
as  much  as  half  the  corneal  base  (one-half  the  diameter),  and  more 
rarely  still,  as  little  as  one-third  (one-fourth  the  diameter),  the 
average  being  about  two-fifths  of  the  diameter,  or  about  7/16  of  the 
circumference. 

Conjunctival  Bridge. — The  conjunctival  flap  has  in  some 
instances  been  left  undivided  posteriorly.  Pensier,  of  Avignon, ^ 
and  Vacher,-  of  Orleans,  hopng  thereby  to  more  surely  prevent 
vitreous  loss  prolapse  and  inclusion  of  the  iris  from  simple  extraction, 
conceived  the  idea  of  leaving  a  broad  strip  of  conjunctiva  uncut  at 
the  summit  of  the  incision,  then  delvering  the  lens  and  removing  the 
cortex  from  beneath  this  bridge.  They  made  upward  section. 
Desmarres  is  said  to  have  operated  similarly,  with  downward  sec- 
tion, nearly  sixty  years  ago.  Others  left  the  bridge  only  until  the 
blepharostat  was  removed,  in  order  to  prevent  vitreous  escape,  and 
then  divided  it  before  proceeding  with  the  extraction. 

Subconjunctival  Extraction. — Czermak  went  further  and 
evolved  his  "conjunctival  pouch"  operation  (Fig.  292).  Czermak's 
object  was  to  render  the  eye  safer  from  both  primary  and  secondary 
prolapse  and  infection,  especially  to  protect  the  wound  during  the 
period  of  healing,  from  outward  contamination,  and  to  avert  pro- 
lapse of  the  iris.  The  section  was  made  downward  when  iridectomy 
was  to  be  omitted,  and  upward  when  not.  The  incision  was  begun 
with  a  3  mm.  broad  Graefe  knife  by  puncturing  the  anterior  cham- 
ber via  a  long  conjunctival  route,  withdrawing  the  knife,  then  ex- 
tending the  conjunctival  cut  downward  and  outward  (or  upward 
and  outward,  as  the  case  might  be),  and  undermining  the  conjunctiva 
about  the  site  of  the  pro])oscd  incision.     The  latter  was  completed  by 

1  "L'extraction  sous  conjuiKiiwilo  de  la  cataract,"  Ann.  d'oc,  1899,  T. 
cxxii,  p.  267  et  1900. 

-  "0])eration  de  la  cataractc  i)ar  Ic  jjrocrdc  a  pont  sclcroconionctival," 
xiii.      Congr.  intern,  des  sc.  im'd.,  sccl.  d'()])lit.,  Paris,  iqoo. 


CORNEAL    SUTURE  553 

means  of  scissors.  The  lens  was  delivered,  and  Ihe  cortex  worked  out 
in  the  usual  manner,  the  spoon  or  the  spatula  being  manipulated 
beneath  the  conjunctiva  in  the  pouch.  The  few  advantages  sought 
were  more  than  offset  by  the  added  difficulties  and  complications 
incident  to  this  mode  of  procedure;  though  in  a  few  selected  cases 
the  operation  with  downward  section  is  of  positive  value,  for  instance, 
in  very  deeply  sunken  eyes  and  those  whose  conjunctival  sacs  are 
much  atrophied,  as  from  old  trachoma.  It  has  been  often  observed 
that  gaping  of  the  incision  occurred  ^ 

when  made  beneath  the  conjunctiva  //  ^\ 

or  even  with  too  large  a  flap  of  this  ji  ,....^^^-^y    |1" """'^'■. 

membrane.  ^--^  \ .  ...---'^     11 1 

Suturing  of    Corneal  Wound.—        ^^/^c^^s==si=^^'^'         \ 
First  done,  in  connection  with  extrac-  /        ""'^xtM'^^  ^  j 

tion,  by  H.  W.  Williams,  of  Boston,  in         / 
1866,  the  suture  having  been  put  in  as      / 

the  last  step  in  the  operation.     In  1888,      ■---„ ..--- 

Ferdinand  SaurezdeMendoza  changed  ^^^ 

the  order  and  made  it  the  first  step, 

and  most  of  those  who  have  since  employed  it  have  followed  his 
example.  The  suture  is  introduced  in  the  form  of  two  small  stitches, 
one  corneal  the  other  episcleral.  The  corneal  stitch  is  put  in  first, 
but  it  never  includes  the  entire  thickness  of  the  cornea.  The 
length  of  each  stitch  varies  between  i  and  1.5  mm.  Kalt,  of  Paris, 
who  has  employed  the  suture  in  several  thousand  extractions, 
makes  the  corneal  stitch  vertical  and  the  other  horizontal.  Valude, 
of  the  same  city,  makes  the  corneal  portion  vertical  and  the  other 
obliquely  so.  Stevenson,  of  Akron,  makes  them  both  horizontal,  or 
parallel  (Fig.  293).  This  arrangement  gives  two  threads  crossing 
the  incision  without  any  additional  passing  through  of  the  needle, 
and  makes  the  strain  at  right  angles  to  the  stitch-canals.  (Fig.  294.) 
The  stitches  are  always  placed  as  near  together  as  will  barely  admit  of 
completing  the  corneal  section  in  the  interspace.  The  loop  of  the 
suture  is  left  long,  and  laid  meanwhile  upon  moist  gauze  or  cotton. 
As  soon  as  the  lens  is  delivered  the  loop  is  drawn  down  by  pnllini^ 
on  ihe  scleral  end  of  (he  thread.  The  suture  is  now  tied,  after  which 
the  toilet  may  be  made  with  deliberation  and  completeness.  Cor- 
tical remains  are  removed  by  a  suction  apparatus.  A  slight  pucker- 
ing of  the  cornea  denotes  that  the  thread  has  been  pro})erly  knotted. 
A  loose  suture  is  without  value.     It  is  removed  on  the  third  day. 


554 


EXTRACTION   OF   CATARACT 


While  making  the  section  if  the  thread  should  be  cut  it  is  put  back 
through  the  same  holes. 

The  advantages  claimed  for  the  corneal  suture  in  extraction  are 
as  follows:  The  toilet  of  the  eye  may  be  more  thorough  and  freer 
from  risk;  the  patient  may  be  allowed  more  freedom;  the  chances  of 
iris  prolapse  are  lessened.  It  is  objected  to  upon  the  grounds  that 
it  is  dilTicult  to  place  with  precision;  it  prolongs  the  operation;  it 
irritates  the  eye;  it  requires  an  operation  for  its  removal;  and  that  it 
does  not  greatly  lessen  the  number  of  prolapses  and  incarcerations, 
nor  does  it  shorten  the  healing  process. 


Fig.  293. — Corneal  suture  placed  pre- 
paratory to  extraction. 


Fig.  294. — The  operation  completed 
and  suture  tied. 


Suturing  of  the  conjuncti\al  llap  has  also  been   tried  but  has 
not  gi\cn  satisfactory  results. 

Opening  the  Capsule. — From  David's  time  down  to  the 
present,  the  prevailing  method  of  opening  the  capsule  has  been  to 
cut  or  scratch  it  by  means  of  a  pointed  instrument — either  a  straight 
or  an  angular  needle  with  one  or  both  edges  cutting,  or  a  combi- 
nation of  knife  and  needle.  The  position  and  extent  of  the  cut  have 
been  much  varied  (see  Fig.  295).  That  is  to  say,  theoretically  they 
have  been  of  such  and  such  forms,  but,  in  reality,  the  figure  assumed 
by  the  rent  in  the  anterior  capsule  has,  doubtless,  been  a  very  non- 
descript   sort    of  affair.      Knap])    has  said  of    it,    "mostly,    it    (^the 


FOKMS    OF    CAPSl'I.OTOMY  555 

capsulolomy)  consists  in  an  extensive  and  j)romiscuous  laceration." 
The  ])articular  style  or  direction  of  the  capsulotomy  is  generally 
supposed  to  have  some  bearing  upon  the  healing  process  and,  also, 
upon  the  frequency  of  secondary  cataract.  Unquestionably,  that 
manner  of  capsulotomy  which  gives  the  greatest  number  of  stray 
fragments  or  shreds  would  be  the  kind  most  often  to  exert  an  evil 
influence  u|)on  the  wound  healing,  but  over  its  power  to  affect  the 
density  of  the  membranous  remains  or  secondary  cataract  one  has 
but  little  control.     The  author  believes,  with  Panas,  that  it  is  not  so 

@©©(§)(>)®0@Q 


Fig.  295. — Forms  of  capsulotomy.  The  circle  represents  the  dilated  jjupil.  Those 
incisions  that  make  angles  whose  bases  are  toward  the  corneal  incision  are  bad  because 
their  flaps  and  tags  get  into  the  wound  to  cause  iris  prolapse  and  to  delay  healing, 
a,  Von  Graefe.  b,  Von  Graefe,  (crucial),  c,  Von  .Arlt.  d,  \'on  .\rlt.  e,  Weber. 
f,  DeWecker.     g,  Knapp.     h,    Czermak.     i,  Agnew. 


much  the  method  pursued  in  the  cystotomy,  as  the  amount  of 
abandoned  lens  remains  that  predisposes,  or  not,  to  the  formation 
of  secondary  cataract. 

A  number  of  operators,  first  and  last,  have  followed  the  example 
of  the  Barons  de  Wenzel  (father  and  son),  who  in  the  latter  part  of 
the  iSth  century  (about  1786),  began  the  practice  of  making  the 
capsulotomy  with  the  point  of  the  corneal  knife  or  keratome — 
chcDii)!  faisaiit,  as  they  expressed  it;  i.e.,  after  making  the  ])unclure, 
the  point  of  the  knife  is  advanced  to  the  pupil,  depressed  till  in  con- 
tact with  the  capsule,  a  certain  movement  is  made  to  incise  the 
capsule,  and,  following  this,  the  counterpuncture  is  made,  and  the 
section  completed  in  the  ordinary  way.  Among  those  who  have 
of  late  years  revived  this  old  method  have  been  Gayet,  of  Lyons, 
and  Galezowski  and  Trousseau,  of  Paris.  The  last  operator  goes  so 
far  as  to  employ  no  other  instrument  in  the  entire  operation  of 
simple  extraction  save  the  Graefe  knife. 


556 


EXTRACTION    OF    CATARACT 


The  guiding  principle  in  the  making  of  the  capsulotomy  and 
corneal  section  simultaneously  is  the  lessening  of  the  hazards  of 
the  operation  by  the  insertion  of  the  fewest  instruments  possible. 
Now,  however  commendable  this  may  be  and  clever  as  is  the  feat, 
it  is  not  good  surgery.  Each  of  the  operative  steps  is  of  too  great 
importance  to  be  accomplished  by  a  bungling  compromise  which  is 
disparaging  to  both.  For,  as  to  the  capsulotomy,  it  is  apt  to  be 
insufficient  and  wrongly  placed.  If  there  is  an  opaque  liquid 
(Morgagnian)  within  the  capsule,  this  escapes,  thus  obscuring  the 
field  and  embarrassing  the  operator;  and  if  the  capsule  is  resisting, 


Fig.   296. — Fuchs'  capsule  FiG.  297. — Fisher's  cap- 

forceps,  sule  forceps.     The  operator 

faces  the  patient — pulls  the 
tips  into  the  chamber,  seizes 
the  capsule,  and  pushes  the 
tips  out. 

there  is  greater  risk  of  rupturing  the  zonule.  It  also  inclines  to 
jaggedness  of  the  corneal  incision  and  premature  escape  of  the 
aqueous,  all  of  which  but  tends  to  vitiate  the  result. 

Daviel  practised  plucking  out,  or  arrachemcnt.  of  the  anterior 
capsule  when  it  was  thickened,  etc.  De  Wecker,  of  Paris,  thought 
to  advance  the  status  of  cataract  e.xtraction,  especially  in  regard  to 
immunity  from   after  cataract,  l)y  tearing  away  all  or  a  portion  of 


REMOVAL    OF    LENS    REMAINS  557 

the  anterior  capsule  as  a  systematic  measure,  and  withdrawinf^^  it 
from  the  eye.  For  this  he  had  constructed  a  pair  of  specially 
designed  forcei)s,  with  sharj)  back  teeth,  which  he  named,  "  forcejjs- 
cystotome."  These  he  used  with  more  or  less  regularity  for  a  time, 
and  could  boast  of  having  his  example  followed  by  such  men  as 
Schweigger,  Knapp,  and  Fuchs  but  the  procedure  fell  into  disuse, 
saving  for  a  few  chosen  cases,  such  as  lenses  with  opaque  capsules. 
Within  the  past  ten  years  there  has  been  a  great  revival  of  arrache- 
ment  because  of  the  lessened  number  of  cases  that  require  opera- 
tions for  secondary  cataract  following  its  employment,  as  compared 
with  capsulotomy.  As  a  result  at  least  a  round  dozen  different 
modifications  in  the  form  of  capsule  forceps  have  appeared  in  the 
decade.  The  shortcomings  of  the  method  are  in  many  respects 
similar  to  those  of  combining  the  cystotomy  with  the  corneal  sec- 
tion, viz.,  uncertainty  as  to  the  extent  and  character  of  the  opening 
and  rupture  of  the  zonule  from  the  pressure  that  must  be  made  in 
order  to  seize  the  capsular  membrane.  It  is  difficult  of  accomplish- 
ment through  a  small  pupil,  hence,  better  adapted  to  cases  in  which 
a  coloboma  of  the  iris  exists. 

I  prefer  Knapp's  peripheral  capsulotomy  to  others  because  it 
gives  the  most  rationally  situated  opening  for  the  exit  of  the  lens; 
it  lends  itself  to  the  horizontal  manipulation  of  the  cystotome; 
being  close  up  under  the  incision,  the  impulse  of  the  lens  as  it  rises 
in  the  direction  of  least  resistance  can  be  readily  observed. 
Where  an  iridectomy  has  been  made,  the  coloboma  affords  an  open 
field  for  nearly  the  requisite  length  of  the  incision;  yet,  a  small 
round  pupil  does  not  interfere  with  its  proper  making,  since  the 
extremities  can  easily  be  extended  beneath  the  iris.  It  has  not  been 
proven — as  has  been  asserted — that  it  leads  oftener  than  any  other 
method  to  the  formation  of  after-cataract. 

Expelling  the  Lens. — For  this,  instead  of  using  spoons,  ex- 
ternally applied  to  the  globe,  some  surgeons  resort  to  pressure  with 
the  fingers,  placed  either  directly  upon  the  eyeball  or  acting  through 
the  medium  of  the  lids.  When  we  reflect  how  utterly  impracticable 
it  is  to  rid  the  fingers,  the  conjunctiva,  the  cilia,  and  the  orifices  along 
the  lid  margins  of  bacteria,  the  clumsiness  of  this  measure  is 
lost  sight  of,  and  we  wonder  only  at  its  uncleanliness — surgically 
speaking. 

Clearing  Out  Lens  Remains.— Irrigation  of  the  anterior 
chamber  for  washing  out  the  cortex  has  been  variously  tried,  as  to 


55o  EXTRACTION  OF  CATARACT 

the  instrument,  the  technic,  and  the  quality  of  the  liquid  employed, 
and,  for  the  most  part,  abandoned,  it  being  ineffective  for  any  but 
the  light,  fluffy,  and  more  innocuous  kind  and,  at  the  same  time,  too 
often  provocative  of  unfavorable  reaction.  Panas  has  been  re- 
ferred to  as  the  originator  of  this  process,  which  is  an  error,  as  his 
lavage  was  purely  to  free  the  anterior  chamber  of  possible  sepsis. 
Its  real  origin  goes  much  farther  back — even  to  Guerin,  and  the 
year  1773.  It  was  little  practised,  however,  till  revived  by  Heymann,^ 
who  used  physiologic  salt  so'ution  for  cleansing  the  eye  of  blood. 


Fig.   298.— Th 


inu'     iiu'lhoil  (if    ninj\in^   i  urtii; 
with  one  spoon  by  Elschnig. 


1  remains  as  practiced 


Since  that  few  have  not,  at  some  time,  tried  it,  in  conjunction  with 

extraction,  yet  few  also  have  become  advocates  of  it  as  a  routine 

practice.     The  chief  exponent  of  the  measure  in  this  country  is 

Lij)j)incott,2  of  Pittsburg;  and  the  latest  model  of  his  irrigator  is 

probably  the  most   suitable  instrument  for  the  purpose.     Lately  a 

small  coterie  of  ophthalmic  surgeons  at  Bordeaux^  have  insisted 

that  the  double-cannula  jjiston  syringe,  for  simultaneous  injection 

and  aspiration,  is  the  only  fitting  inslrimient.     A  re\-iew  of  the  sub- 

•  Klin.  .Mhl.  f.  Aug.,  18O4.  S.  305. 
■-  Am.  Jour,  of  ()])h'y.,  July,  1004. 
'  Archives  (roi)lit;ilinii1(isj;if,  I'd).,   11)05. 


SPECIAL    METHODS  559 

ject  by  the  present  writer  is  to  be  found   in  the  O l)hlh<iliiiir  Record 
for  March,  IQ05. 

Fuchs,  of  Vienna,  actually  })uls  a  s])oon,  similar  to  Desmarrcs', 
into  the  anterior  chamber  and  ladles  out  the  remain in<^  cortex. 
This  seems  a  bold  proceeding,  though  it  works  to  the  entire  satis- 
faction of  its  distinguished  partisan,  which  counts  in  its  favor. 

COMPLICATED  AND  SOFT  CATARACTS  AND  SPECIAL 
MODES  OF  EXTRACTION. 

Under  this  heading  may  be  classed  all  those  cataracts  that  do  not, 
generally  speaking,  admit  of  being  handled  according  to  the  methods 
already  described  or  by  the  treatment  to  which  other  methods  are 
better  adapted.  Among  these  may  be  mentioned  shrunken,  ad- 
herent, dense  membranous,  tremulous,  dislocated  and  soft,  swollen 
cataracts  causing  glaucoma  after  discission.  A  brief  discussion  of 
them  in  the  order  of  their  importance  follows. 

Linear  Extraction. — This  term  refers  to  the  manner  of  making 
the  incision  (full  linear  incision  has  already  been  spoken  of). 
To-day,  when  one  uses  the  term,  it  means  merely  an  incision  with 
the  lance-knife  or  keratome,  and  is  the  kind  best  fitted  for  several  va- 
rieties, of  cataract — notably,  shrunken  cataracts,  those  membranous 
cataracts  that  are  too  dense  or  too  tough  for  ordinary  discission, 
zonular  cataracts,  and  for  the  extraction  of  those  swollen  lens  masses 
that,  after  discission,  cause  serious  reaction,  such  as  high  tension, 
etc.  In  truth,  it  is  my  belief  that  the  keratome  could,  in  many 
instances,  be  used  with  advantage  to  supersede  the  Gracfe  knife. 

Advantages  of  the  Keratome. — Its  wound  heals  with  exceptional 
readiness  and  kindliness.  This  is  probably  owing  to  the  fact  that 
it  lies  chiefly  in  one  plane,  without  notching  and  other  unevenness. 
The  aqueous  humor  can  be  better  controlled,  i.e.,  it  can  be  more 
surely  held  back  or  evacuated  with  greater  discernment;  hence,  also, 
the  iris  behaves  better;  the  act  of  making  the  cut  is  less  startling 
to  the  patient  and  he  remains  more  quiet,  thus  reducing  the  risks. 
So,  for  these  and  other  reasons,  the  incision  can  be  more  accurately 
placed.  The  most  commonly  urged  objection  to  the  keratome  for 
cataract  extraction  is  that  the  wound  opening  is  too  small.  If  one 
will  practise  on  pigs'  eyes,  the  making  of  a  surprisingly  large  ()])en- 
ing,  of  very  short  wound  canal,  is  speedily  arrived  at.  The  essentials 
are  that  the  blade  be  extra  broad,  that  in  starting  the  cut  the  plane 


560  EXTRACTION  OF  CATARACT 

of  the  blade  be  held  about  at  a  right  angle  to  the  corneal  curve  until 
the  ])oint  enters  the  anterior  chamber,  then  depressed  till  it  is  parallel 
with  the  plane  of  the  iris,  holding  strictly  to  this  and  advancing 
until  the  point  cannot  be  pushed  any  further.  Then  the  heel  of 
the  knife  is  turned  to  the  side  where  the  cutting  lacks  most,  holding 
if  possible  to  the  same  plane,  and  the  incision  is  extended  while 
withdrawing  the  blade.  It  is  my  custom,  when  a  long  cut  is 
needed,  to  begin  not  in  the  vertical  meridian,  but  a  little  to  the 
left  of  it,  and  fmish  by  lengthening  it  to  the  right.  The  eye  must 
be  carefully  steadied  during  this  final  maneuver,  the  knife  held 
very  firmly,  and  the  sweep  that  makes  the  extension  be  executed  not 
too  swiftly,  else  the  patient  may  wince,  or  the  direction  of  that 
part  of  the  incision  be  faulty  or  dangerous.  In  this  way,  the 
anterior  chamber  being  of  normal  or  greater  than  normal  depth,  a 
wound  opening  measuring  a  centimeter  or  more — quite  ample  for  the 
exit  of  an  average  sized  lens — can,  after  a  little  preliminary  practice, 
as  suggested,  be  quite  readily  accompl'shed.  It  is  most  suitable 
for  purposes  of  extraction  when  it  lies,  throughout,  barely  anterior 
to  the  apparent  sclero-corneal  junction. 

If,  after  all,  the  incision  seems  inadequate,  it  can  be  enlarged 
with  scissors  or  blunt-curved  knife.  That  these,  or  one  of  them, 
arc  at  hand,  ready  prepared  and  extra  sharp,  goes  without  saying. 
If  a  conjunctival  flap  is  desired,  it  may  be  first  fashioned  with 
forceps  and  scissors,  then  turned  down,  over  the  cornea,  and  the 
keratome  incision  proceeded  with. 

Shrunken,  adherent,  and  dense  capsular  are  several  qualities 
often  found  in  a  single  cataract.  They  are  most  frequently  met 
with  in  old  traumatic  cataracts,  particularly  those  that- have  been  at 
some  time  attended  with  partial  absorption  or  inflammatory  proc- 
esses, and  are  characterized  by  calcific  and  connective-tissue 
degeneration.  Not  unlike  these,  in  many  respects,  are  the  shriveled 
and  generally  anomalous  varieties  of  congenital  cataract.  These 
and  the  dislocated  cataracts,  in  short,  all  that  are  not  best  dealt 
with  by  the  flap  operations,  previously  described,  or  by  discission, 
are  proper  subjects  for  extraction  with  keratome  incision.  In  but 
few  is  the  use  of  the  cystotome  indicated.  In  that  form  where  there 
is  considerable  posterior  synechia  with  dense  anterior  capsular 
opacity — which  makes  the  plucking  out  of  the  latter  with  the 
back-tooth  forceps  impracticable — it  is  best  to  make  preliminary 
iridectomy.     This  will  expose  a  greater  area,  wherein,  when  it  comes 


SPECIAL    MEllIODS  561 

lo  ihe  (jxlraciion,  a  fair  and  sufficient  cai)sul()l()my  can  be  made  and 
the  lens  expelled  in  the  regular  manner.  A  subsec^uent  discission 
of  the  thick  membranous  cataract  which  is  left  behind  is  usually 
sufficient  to  establish  a  good  jnipil.  In  the  event  of  dense  anterior 
capsular  cataract  icilhoiit  a  great  deal  of  jjosterior  synechia,  with- 
drawal with  the  ca])sule  forceps  is  a  good  ])rocedure.  It  may 
happen  that  the  lens  will  come  out  with  it — so  much  the  better; 
but  it  is  well  to  watch  closely  and  be  prepared  for  this  contingency. 

Whenever  preferable,  from  inability  to  dilate  the  pupil  or  any 
cause,  to  make  ir.dectomy  in  these  peculiar  cases,  the  preliminary 
is  the  best.  There  will  then  be  no  blood  in  the  anterior  chamber 
to  hamper  the  extraction,  the  degree  of  traumatism  will  be  less  and, 
moreover,  one  learns  something  of  the  character  of  the  patient 
before  reaching  the  more  critical  operation  of  extraction.  An 
upward  iridectomy  and  extraction  are  preferable,  though  the  position 
of  the  least  number  of  iris  adhesions  or  of  a  dislocated  lens  will 
sometimes  furnish  reasons  for  departing  from  the  rule.  In  all  save 
those  in  which  a  regulation  capsulotomy  is  feasible,  a  traction  instru- 
ment for  the  getting  out  of  the  cataract  will  be  necessary.  My 
preference  is  for  the  open  sharp  hook  for  the  lenses  and  the  blunt 
hook  or  iris  forceps  for  the  mats.  Each  operator  must  decide 
as  to  whether  local  or  general  anesthes'a  be  employed  in  a  given 
case.  I  have  made  a  great  number  of  extractions  of  complicated 
cataracts,  many  of  which  were  luxated,  and  I  have  not  resorted  to 
general  anesthesia  as  many  as  three  times. 

For  the  better  elucidation  of  this  subject,  permit  the  citing  of 
actual  cases  illustrative  of  the  several  kinds  of  cataracts  and  of  the 
methods  alluded  to  in  this  chapter,  wherein  they  were  j)ut  by  the 
author  to  a  practical  and  successful  test. 

Case  I.  Example  of  Extraction  of  a  Shrunken,  Lightly 
Adherent  Cataract,  with  Calcific  Degeneration  of  the  Anterior 
Capsule. — Stewart  S.,  age  22,  farmer.  Came  to  me  September  15, 
1903.  At  age  of  7  years  received  blow  in  the  right  eye  from  end  of 
stick  in  the  hand  of  a  small  brother.  Jn  due  time  the  sight  of  the 
eye  failed  and  the  pupil  looked  white.  The  central  portion  of  the 
cataract  was  snow-white  and  dense.  The  iris  was  adherent  below, 
while  the  rest  of  the  pupil  dilated  fairly  well.  The  denser  portion 
of  the  cataract  was  about  the  size  of  the  normal  pupil,  the  rest  was 
gray  with  radiating  streaks  of  white,  and  the  wliole  looked  shrunken. 

The  o])eration   occurred    September   17,   1903,  at  the  Passavant 
^.6 


562  EXTRACTION  OF  CATARACT 

Hospital.  Cocain.  Incision  with  broad  keratome  was  made  at  the 
upper  sclero-corneal  junction  and  the  jjoint  of  the  knife  made  to  incise 
the  zonule  below.  While  the  upper  lid  was  held  back  by  an  assist- 
ant, Ue  Wecker's  capsulotomy  forceps,  or  forceps  cystotome,  was 
introduced,  the  thick  portion  of  the  capsule  was  seized  and  with- 
drawn. This  set  free  the  small,  hard,  opaque  lens,  about  the  size 
and  shape  of  a  lentil.  Behind  this  the  small  sharp  hook,  of  well 
o])en  pattern,  was  inserted  llatwise,  then  turned  point  forward  and 
the  lens  caught  and  delivered.  After  closing  the  eye  and  waiting  a 
few  moments,  the  iris,  although  it  had  been  pulled  slightly  into  the 
wound,  was  found  again  in  place  with  round  pupil.  There  was  no 
loss  of  vitreous.  The  eye  recovered  promptly,  but  with  little  vision, 
owing  to  rupture  of  the  choroid  caused  by  the  original  injury. 
The  patient  returned  to  his  home  in  Iowa  on  the  26th  of  the  same 
month. 

For  cases  of  complete  posterior  synechia  with  cataract,  where 
an  attempt  at  iridectomy  would  but  result  in  stripping  off  the  outer 
layers,  leaving  the  uvea  on  the  capsule,  and  where  the  anterior 
chamber  is  extremely  shallow,  the  operation  of  de  Wenzel  might 
be  resorted  to.  The  elder  de  Wenzel,  about  a  century  and  a 
(juarter  ago,  devised  an  operation  for  that  forlorn  class  of  cases 
characterized  by  very  extensive  or  total  posterior  synechia  with 
thickened  anterior  capsule  or  atresia  of  the  pupil,  shallow  anterior 
chamber,  etc.,  that  is  not  a  bad  procedure  to-day.  It  wjls  the 
making  of  a  large  corneal  flap  just  as  for  the  ordinary  extraction, 
except  that  it  included  the  iris  and  lens.  In  other  words,  the  knife 
was  made  to  pass  through  these  tissues  as  if  they  did  not  exist. 
Then  as  much  as  was  practicable  of  the  iris  flap  was  excised,  and 
the  lens  expelled  by  external  pressure.  Snellen,  "  Operationslehre," 
of  the  Gracfe-Saemisch  Handbook,  p.  46,  cites  the  case  of  an  eye 
upon  which  he  himself  made  the  de  Wenzel  operation  with 
brilliant  success. 

(\isc  2.  Example  of  Extractions  of  Congenital  Capsulo- 
lenticular  Cataract.  Agnew's  Modified  Hook  Operation. — 
This  is  the  method  by  which,  while  ser\-ing  as  house  surgeon,  I  had 
seen  Dr.  Agnew,  of  New  York,  make  extraction  in  similar  cases, 
at  the  Manhattan  Eye  and  Ear  Hospital.  I  know  that  his  Jirst 
hook  extractions  were  made  as  follows : 

He  first  introduced  a  strong  needle  through  tlie  cornea,  infero- 
Icmjiorally  (for  the  right  eye),  passed  it  through  the  lower  junction 


SPECIAL    METHODS  563 

of  cataract  and  zonule,  <z;a\c  it  a  rocking  motion  lo  enlarge  the 
opening  slightly,  held  the  needle  there  to  fix  the  eye,  made  kerattjme 
incision  above,  and  put  in  a  Ijlunt  hook.  He  then  withdrew  the 
needle  and  inserted  the  hook  at  the  opening  madr  in  the  cataract 
by  the  needle,  pulled  out  the  cataract  and  had  an  assistant  cut  its 
zonule  oil  as  one  would  the  iris  in  iridectomy.  He  had  aban- 
doned this  method  before  my  connection  with  the  hospital  and 
before  I  became  familiar  with  his  work.  His  later  mode  of  i)ro- 
ccdure  is  embodied  in  the  case  here  cited. 

Archie  K.,  age  i6  months,  German.  Brought  by  his  parents  May 
3,  1888.  Born  with  "white  pupils."  There  were  also  convergent 
strabismus  and  nystagmus.  The  pupils  dilated  freely  under 
mydriatic.  Cataracts  were  exactly  ahke  in  both  eyes.  The  central 
portions,  occupying  an  area  above  the  size  of  the  normal  pupil,  were 
dense,  thick,  and  chalky-white,  of  irregularly  rounded  outline. 
Radiating  from  these  were  numerous  streaks  of  white  and  gray,  in 
places  so  thin  as  to  be  almost  transparent,  the  whole  having  a 
wrinkled  appearance  and  apparently  containing  no  soft  material. 
Evidently,  not  a  case  for  either  discission  or  dilaceration.  Advised 
extraction. 

June  15,  1888.  Agnew's  blunt-hook  operation,  the  technic  of 
which  is  as  follows:  Right  eye.  Pu])il  dilated.  Chloroform. 
Superior  keratotomy  with  lance-knife  or  iridectomy  knife,  point 
pushed  far  in  and  thrust  through  the  cataract,  or  rather  through 
the  zonule,  below  the  thicker  portion,  and  behind  ihe  lower  border 
of  the  pupil.  While  an  assistant  steadied  the  eye  with  the  fixation 
forceps,  I  took  the  blunt  hook  in  the  left  hand  and  iris  scissors  in 
the  right,  introduced  the  former  at  the  wound,  inserted  the  ])oint 
in  the  cut  made  through  the  cataract  below,  made  slow  traction,  at 
the  same  time  giving  the  handle  of  the  hook  about  a  quarter  turn 
on  its  long  axis,  so  as  to  pass  the  crook  flatwise  through  the  incision, 
drew  out  all  the  tliicker  portion  of  the  cataract  and  cut  off  the 
adherent  zonular  shreds  close  to  the  cornea.  No  loss  of  vitreous, 
no  iris  complications.     Quick  recovery  with  round  black  pupil. 

August  2,  1888.  The  same  operation  was  made  on  the  left  eye. 
Same  result,  except  that  a  single  adhesion  occurred  below,  where  the 
iris  was  so  drawn  upward  as  to  produce  a  heart-shai)ed  pupil.  This 
was  later  freed  by  discission  and  the  pupil  became  round.  The  boy 
was  last  seen  in  August,  iSgy,  wlien  1  made  advancement  of  the  left 
externus   for   the   correction   of   the   squint.     At   this   time,    when 


564  EXTRACTION  OF  CATARACT 

sent  back  to  his  home  in  Ohio,  there  was  no  strabismus,  the  nystag- 
mus was  hardly  perceptible,  and  the  vision  of  each  eye,  with  lens 
of  +10  D,  was  20/70.  The  reduced  vision  being  due  to  lack  of 
development  of  the  retime  and  choroidea,  common  to  these  cases. 

I  have  since,  in  numerous  instances,  availed  myself  of  the  great 
advantages  afforded  by  this  procedure,  and  always  with  most  grati- 
fying results.  It  is  specially  applicable  to  certain  forms  of  congenital 
cataract,  such  as  the  irregular  zonular  type,  that  are  of  stunted 
growth,  and  are  more  or  less  apaque  throughout;  also  to  the  dry 
largely  membranous  ones,  named  by  Schmidt  "aride  siliqueuse" 
cataracts.  The  measure  is  equally  suitable  for  the  extraction  of 
many  of  the  shrunken  traumatic  cataracts.  A  trained  assistant  is 
needed,  particularly  if  narcosis  is  employed,  to  fix  the  globe,  after 
the  incision  is  made,  leaving  the  operator  free  to  use  both  hands  in 
manipulating  hook  and  scissors. 

Case  4.  Example  of  Extraction  of  Large,  Slightly  Luxated, 
Tremulous  Morgagnian  Cataract.  Angelucci's  Fixation.— 
Robert  Cummings,  age  64,  shoemaker.  Admitted  to  the  Illinois 
Charitable  Eye  and  Ear  Infirmary,  October  i,  1903.  Left  eye  be- 
came inflamed  and  sight  impaired  twelve  years  ago,  and  has  since 
been  subject  to  frequent  attacks  of  pain  and  redness  with  gradual  loss 
of  vision.  Lost  sight  of  right  eye  six  weeks  or  two  months  ago. 
Condition  on  admission:  right  eye  sHghtly  red;  cataract  of  an  even 
whiteness;  iris  molded  to  the  lens,  and  both  very  tremulous;  pupil 
responds  to  mydriatic.  The  lens  is  misplaced  slightly  inward. 
Anterior  chamber  rather  deep,  T  normal,  fair  perception  of  light, 
field  and  projection  faulty.  Left  eye  dusky  red,  globe  very  soft. 
Myosis.  Iris  adherent  to  anterior  capsule  of  lens,  the  latter  being 
thick  and  while.  Bare  perception  of  light,  with  field  of  vision  and 
projection  lacking. 

Seeing  that  capsulotomy  is  out  of  the  question  in  the  extraction 
of  a  dislocated  lens,  the  incision  is  followed  immediately  by  the 
delivery  of  the  lens  with  a  traction  instrument.  The  incision  is 
sometimes  best  made  with  the  Gracfe  knife,  though  occasionally 
with  the  keratome,  and  llie  operator  must  use  his  judgment,  in  view 
of  the  size  and  relation  of  the  lens  to  its  surroundings. 

For  the  extraction  made  in  this  case,  the  writer  availed  himself 
of  the  method  of  fixing  the  eye  and  of  liolding  it  open,  devised  by 
A.  Angel ucci.' 

1  Arch,  (li  ott.,  vol.  v,  fasc.  3-4. 


SPECIAL    MKTIIODS  565 

October  5,  1903.  Preliminary  iridectomy  of  right  eye.  Followinj^ 
the  excision  of  the  iris,  notwithstanding  the  fact  that  the  patient's 
Ijehavior  was  the  very  best  and  nothing  was  ])ressing  on  the  eye,  a 
small  quantity  of  thin  vitreous  llowed  from  the  wound.  After  this, 
all  went  well  and  the  eye  was  quiet  by  the  lolh  of  tlie  month. 
Through  the  large  coloboma,  the  milk-white  cataract  could  be  seen 
extending  very  far  out,  i.e.,  the  equator  of  the  lens  was  not  yet 
in  view.  The  problem  that  now  presented  itself,  was  how  to  extract 
the  cataract  with  promise  of  smallest  loss  of  vitreous.  Resolved  to 
try  the  method  of  Angelucci.  This  is  to  hold  the  globe  by  seizing 
with  strong  tixation  forceps  (no  catch)  the  tendon  of  the  superior 
rectus  muscle.  This  was  put  into  execution  (3ctober  29th,  and  my 
sincere  thanks,  as  well  as  those  of  the  patient,  are  due  the  noted 
Italian  surgeon  for  a  measure  that  was  truly  an  inspiration. 

The  eye  was  cocainized,  the  upper  lid  held  back,  the  patient  told 
to  look  down,  and  the  whole  tendon  of  the  superior  rectus  was 
caught,  not  in  a  fold,  but  by  placing  a  jaw  of  the  forceps  on  either 
side  of  it.  A  free  upward  section  of  the  cornea  was  made  with  a 
small  Graefe  knife,  the  open  sharp  hook  was  inserted  behind  the 
lens,  dug  into  it,  and,  at  the  first  pull,  the  capsule  ruptured  and 
there  gushed  out  of  the  incision  a  great  quantity  of  liquor  morgagnie. 
It  did  not  get  in  front  of  the  lens,  yet  after  its  escape  the  pui)il  was 
black — no  cataract  was  to  be  seen.  The  first  thought  was,  of  course, 
that  the  hard  nucleus  had  dropped  into  the  vitreous  chamber. 
On  peering  sharply  into  the  coloboma,  however,  there  appeared  the 
merest  glint  of  gray.  Still  keeping  a  firm  hold  on  the  tendon,  the 
hook  was  carefully  passed  flatwise  behind  this  faint  opacity,  point 
turned  forward  and  drawn  out.  With  it  came  a  very  large  nucleus 
of  inky  blackness.  Strange  to  relate,  not  a  drop  of  vitreous  was 
lost,  for  not  only  did  the  grip  on  the  superior  rectus  steady  the  globe 
perfectly,  but  it  served  three  other  most  important  functions,  viz.,  it 
held  back  the  upper  lid,  it  so  paralyzed  the  muscle  that  there  was 
not  the  least  tendency  of  the  eye  to  roll  upward,  and,  most  essential 
of  all,  it  caused  strong  tendency  to  closure  of  the  zvound.  Fixation  by 
the  ordinary  method,  below  the  cornea,  would  have  had  the  opj)Osite 
etifect,  and  there  \vould  certainly  have  been  an  outflow  of  vitreous. 
The  eye  recovered  without  accident  and  the  patient  was  discharged 
Nov.  23d,  with  corrected  vision  of  20/70.  Under  treatment  the 
left  eye  became  quiet.  I  have  a  number  of  times  since,  in  cases 
where  there  was  likely  to  be  loss  of  vitreous  in  an  extraction,  re- 


566  EXTRACTION  OF  CATARACT 

sorted  to  the  Angelucci  fixation,  and  always  with  the  greatest 
satisfaction. 

Case  5.  Example  of  Extraction  of  Cataract  Dislocated  and 
Lying  in  the  Anterior  Chamber. — William  Pearson,  age  34,  coach- 
man. Admitted  to  the  Eye  and  Ear  Infirmary,  October  15,  1892. 
Recurrent  severe  inflammation  and  loss  of  sight  of  the  right  eye. 
Eye  has  been  operated  upon  elsewhere  (iridectomy)  and  had  since 
remained  quiet,  though  with  a  cataract.  The  day  before  coming 
to  the  hospital,  while  bridling  a  horse,  the  animal  in  ^shaking  its 
head,  struck  the  ])atient  a  severe  blow  on  the  right  temple,  when 
he  immediately  felt  that  something  had  happened  to  the  bad  eye. 
Condition  on  admission:  Right  eye  painful,  conjunctiva  injected, 
large  cataractous  lens  in  anterior  chamber,  upward  coloboma 
of  the  iris.     Vision  nil.     Left  eye  normal.     Operation  at  once. 

Eserin  was  used,  but  owing  to  the  pre^•ious  iridectomy,  it  had 
scarcely  any  effect  upon  the  pupil.  While  the  eye  was  being  put 
under  cocain,  I  remarked  to  those  around  that  it  would  be  neces- 
sary to  introduce  a  needle  to  hold  up  the  lens,  else  it  might  drop 
through  the  large  opening  into  the  vitreous.  The  words  were 
scarcely  uttered  before,  through  a  quick  movement  of  the  eye,  the 
cataract  disappeared  in  the  manner  suggested.  I  then  turned  the 
man  over  on  his  stomach  with  his  face  projecting  beyond  the  end  of 
the  table  and  asked  him  to  let  me  manipulate  his  head  as  if  it  were 
not  attached  to  his  body.  By  this  means  the  cataract  was  brought 
again  into  the  anterior  chamber.  He  was  turned  on  his  right  side, 
a  delicate  Bowman  needle  was  inserted,  from  the  nasal  limbus, 
behind  the  lens,  he  was  turned  further  so  as  to  lie  somewhat  on  his 
back,  a  downward  section  of  the  cornea  made  and  the  cataract  ex- 
tracted without  other  accidents.  Recovery  was  prompt  and  the  eye 
appearing  normal  afterward,  save  for  the  old  coloboma. 

Case  6.  Example  of  Extraction  of  Swollen  Lens  Causing 
Severe  Secondary  Glaucoma  After  Discission  for  High 
Myopia.  The  citation  of  this  case  serxcs  more,  perhaps,  to  point  a 
moral  than  to  adorn  a  chapter  on  the  surgery  of  the  eye.  Sophia 
Lee,  12  years  old,  Chinese  girl,  came  under  treatment  May  5,  1900, 
wearing—  ID  D  o\erboth  eyes.  Could  no  longer  see  well  at  a  distance 
with  her  glasses.  Tests  then  showefl  R.  \\=2 '200;  20  50  w  — 16. 
L.  V.  =2/200;  20/70  w  —  i().  (^vh'ndcrs  did  not  improve.  ()])hthal- 
moscope  showed  small  conus  and  \ery  striking ///;/(///.s-  tii^^rcc  in  both 
eyes.     Advised  discissions. 


INTRA-CAPSULAR    OPERATION  567 

September  ii,  igoo,  tentative  discission  in  left  eye,  very  sli<^ht 
reaction;  September  20,  1900,  more  thorough  (hscission  in  left  eye. 
Crystalline  very  soon  broke  up  and  by  February  i,  1901,  had  all 
disappeared,  leaving  a  small  capsular  band  across  the  pupil.  Test 
showed,  L.  \'.  =10 '200;  20  30  +  \v— 2.5  c  ax  155°.  April  i.  upi, 
tirst  slight  discission  in  right  eye.  No  special  reaction.  Ajiril 
23,  1901,  more  decided  operation — capsule  and  lens  well  incised. 
Lens  slowly  broke  up.  About  May  6th  there  was  considerable 
swelling  of  lens  and  some  pain.  Eserin  was  instilled  which  seemed 
to  relieve  the  symptoms,  and  the  child  was  given  a  solution  of  the 
same  to  use  at  home.  Saturday,  May  8,  T  normal  and  eye  fairly 
quiet. 

Although  under  instructions  to  report  often,  and  though  she  had 
been  very  faithful  in  her  attendance  at  my  office,  I  did  not  see  her 
again  until  Wednesday,  May  12,  1901.  The  eye  had  been  very 
painful  since  Saturday  evening  (the  8th),  the  T  was  very  high  and 
the  eye  very  red.  Her  mother  had  objected  to  her  going  out,'  on 
account  of  the  condition  of  the  eye.  I  at  once  made  superior  kera- 
totomy  wath  keratome.  A  c|uantity  of  soft  lens  material  followed  the 
withdrawal  of  the  instrument.  A  thin  spatula  was  inserted  to  hold 
back  the  iris  and  to  form  a  chute  for  the  remaining  masses,  and  by 
manipulation  of  a  hard-rubber  Graefe  spoon  on  the  anterior  surface 
of  the  cornea,  most  of  them  came  out.  The  iris  was  not  disturbed. 
The  eye  immediately  became  comfortable,  was  bandaged,  and,  with 
twenty-four-hour  dressings,  after  a  few  days,  seemed  to  have  re- 
covered. On  examination  of  the  field,  however,  it  was  found  lacking 
on  the  nasal  side.  In  spite  of  treatment  the  defect  persisted  and 
to-day  it  extends  barely  to  the  left  side  of  the  center.  R.  V.  = 
20/200  w-h2cx  90°.  The  vision  of  the  left,  with  glasses,  is  now 
(Jan.,  1904)  20/30  +  2,  and  she  reads  the  finest  print.  Has  been 
regularly  in  school  for  the  past  two  years.  I  should  never  again, 
under  such  circumstances,  allow  the  patient  to  stay  at  home,  but 
should  insist  by  all  means  upon  the  hospital. 

EXTRACTION  OF  THE  LENS  IN  ITS  CAPSULE. 

Beer,  in  Vienna,  at  the  close  of  the  i8th  century,  tried  plunging 
the  lance-knife,  with  which  he  made  the  corneal  incision,  into  the 
lens,  mobilizing  the  latter,  completing  the  section,  then  expelling  the 
lens  by  pression.     Often,  however,  the  cataract  came  out  with  the 


568  EXTRACTION  OF  CATARACT 

knife.  The  first  recorded  extractions  of  the  cataract  and  capsule 
intact  were  made  by  Samuel  Sharp,  of  London,  in  1753.  The 
famous  Gottingen  surgeon,  August  Gottlob  Richter,  took  it  up 
twenty  years  later,  or  about  the  year  1 773.  So,  for  one  hundred  and 
fifty  years  eye  surgeons  have  striven  for  that  ideal — a  safe  method 
of  extraction  of  the  lens  in  its  capsule,  applicable  to  senile  cataract 
in  general — thus,  once  for  all,  doing  away  with  two  of  the  great 
evils — the  residual  cortex  and  the  secondary  cataract.  After  giving 
it  a  fair  trial,  meanwhile  endeavoring  to  correct  its  faults,  these 
illustrious  surgeons  relinquished  it  and  fell  in  with  redination 
instead. 

After  completing  the  corneal  incision,  Richter  expressed  the  lens 
by  steady  and  gentle  squeezing  of  the  globe.  Beer,  at  a  later 
date  (1790),  introduced  a  needle  at  the  incision,  transfixed  the 
cataract,  and  by  moving  it  about  in  various  directions  loosened  the 
zonule,  and  then  extracted  by  external  pressure.  They  both  operated 
downward,  by  large  linear  incision,  and  without  iridectomy.  The 
method  found  few  imitators  and  soon  fell  into  disrepute,  until 
revived,  in  1845,  by  Christisen.  This  operator  made  pressure 
upon  the  globe  just  before  finishing  the  corneal  section,  to  cause 
the  lens  to  break  its  zonule  and  to  present  at  the  wound,  completed 
the  section,  and  expressed. 

From  1865  to  1889,  the  brothers  Alexandre  and  Hermann 
Pagenstecher,  of  Wiesbaden,  by  a  long  series  of  intracapsular  ex- 
tractions, attempted  to  popularize  the  method  while  still  mak- 
ing the  Graefe  modified  linear  incision.  Alexandre  Pagenstecher 
added  to  it  a  large  iridectomy,  then  delivered  the  lens  by  means 
of  his  broad  shallow  spoon.  Later  they  adopted  the  large  corneal 
flap  extraction,  adhering  still  to  the  spoon  delivery,  but  only  for  the 
more  obstinate  lenses  that  did  not  respond  readily  to  pressure.  The 
surviving  brother,  Hermann  Pagenstecher,  has  relinquished  the 
measure  save  for  exceptional  cases.  As  a  result  of  the  favorable 
reports  of  the  operation  by  these  very  able  surgeons,  it  was  taken  up 
by  many  others — in  this  country  by  Knapp  and  Roosa. 

The  last-mentioned  surgeon,  in  1884,  after  a  visit  to  Wiesbaden, 
made  a  number  of  intracapsular  extractions,  but  soon  became  dis- 
couraged by  the  very  high  percentage  of  vitreous  loss.  He  essayed 
the  breaking  of  the  zonule  by  pressing  down  upon  the  lens  with  the 
knife,  just  after  making  the  counterpuncture,  slightly  turning  the 
back  of  that  instrument  toward  the  anterior  capsule  the  while. 


PRELIMINARY    CAPSULOTOM Y  569 

Still  more  recently  (1895)  the  late  Gradcnigo,  of  Naples,  under- 
took it.  After  making  corneal  section,  he  introduced  a  small  and 
specially  constructed  ])lunt  hook,  which  he  called  a  /onulolonie, 
tore  the  zonule  below,  and  expelled  the  lens.  Del^^ado  lirst  niohil 
ized  the  lens  by  entering  a  needle  through  the  cornea,  as  if  for 
discission,  withdrew  it,  made  a  large  peripheral  (scleral)  incision 
upward,  iridectomy,  and  expulsion  of  cataract.  Jn  short,  a  great 
variety  of  ideas  for  division  or  rupture  of  the  zonule  have  been  put 
into  practice.  Yet  any  procedure  whereby  the  zonule  is  torn  or  cut 
before  efforts  are  made  to  express  the  lens  is  open  to  the  serious 
objection  that  the  vitreous  is  more  likely  to  present  itself  at  the 
wound  in  advance  of  the  lens,  thus  rendering  worse  than  useless 
further  attempts  to  expel  the  cataract  by  external  pressure. 

Preliminary  Capsulotomy. — Homer  Smith,  of  Norwich,  N.  Y., 
in  cases  of  immature  cataract,  makes  free  capsulotomy  four  to  six 
hours  previous  to  the  extraction.  ^  We  will  let  him  describe  his 
instruments  and  his  technic.  "It  was  found  that  the  knife  needle 
was  rarely  sufficiently  sharp  clear  up  to  the  point,  that  its  shape 
made  it  catch  in  the  lens  and  if  great  care  was  not  used  the  lens  was 
apt  to  be  dislocated.  To  make  it  more  effective  for  the  purpose 
intended  the  point  was  ground  ofT,  making  the  blade  the  shape  of  a 
miniature  scalpel.  The  shank  was  made  of  equal  size  throughout  so 
that  it  should  fill  accurately  the  puncture  made  by  the  cutting  surface. 
Previous  and  immediate  to  the  operation  itself  the  pupil  is  fully 
dilated  by  a  2  per  cent,  solution  of  homatropine.  The  eye  is  then 
cocainized,  the  aseptic  details  completed  and  the  speculum  inserted. 
If  for  the  right  eye  the  operator  stands  at  the  head  of  the  patient. 
Taking  a  firm  and  deep  grasp,  with  the  fixation  forceps,  upon  the 
conjunctiva  just  below  the  insertion  of  the  internal  rectus  muscle, 
the  knife  above  described  is  thrust  through  the  cornea  about  the 
middle  of  the  supero-temporal  quadrant  and  the  blade  carried  down 
to  the  lower  edge  of  the  dilated  pupil,  its  edge  being  toward  the 
operator.  The  handle  is  then  made  to  describe  the  arc  of  a  circle 
away  from  the  surgeon  and  a  cut  is  made  through  the  capsule  up 
to  the  upper  limit  of  the  pupil,  the  blade  then  slightly  withdrawn 
is  carried  over  to  the  inner  side  of  the  mid-pupillary  space,  the 
same  maneuver  repeated  and  a  cut  made  in  the  capsule  at  right 
angles  to  the  first.  The  blade  is  then  turned  into  the  same  plane 
as  its  entrance  and  is  withdrawn.  If  for  the  left  eye  the  operator 
1  Jour,  of  Oph.  and  Oto-Laryn.,  Sept.,  1911. 


570  EXTRACTION  OF  CATARACT 

Stands  on  the  left  side  of  the  jjatient,  the  fixation  is  just  above 
the  internal  rectus  and  the  knife  entered  in  the  infqro-temporal 
(juadrant,  the  cut  in  the  cajjsule  then  begins  at  the  upper  limit  of 
the  jnipil.  The  procedure  otherwise  is  the  same.  After  the  cap- 
sulotomy  the  conjunctival  sac  is  flushed  with  an  antiseptic  lotion, 
the  ])atient  given  a  hypodermic  of  1/4  grain  of  morphia  and  put  to 
bed.  He  is  allowed  to  remain  there  from  four  to  six  hours  before 
the  extraction  ])roper  is  performed.  This  does  not  differ  from 
the  ordinary  method  but  the  corneal  section  should  be  ample  for 
most  immature  cataraclous  lenses  are  large.  The  period  of  wait- 
ing and  the  method  of  the  capsulotomy  are  the  two  essentials  of 
this  operation.  What  happens  during  the  waiting  period  is  this: 
The  capsule  having  been  amply  divided  curls  aw^ay  from  the  cor- 
tex and  allows  the  aqueous  to  insinuate  itself  betw^een  this  and 
what  remains  of  the  en\eloping  capsule,  causing  a  separation  be- 
tween the  two.  That  this  is  true  is  seen  by  the  ease  with  which 
the  later  delivery  of  the  lens  is  always  accomplished  and  its  clean, 
full  and  smooth  outlines  when  it  does  come  out." 

"INDIAN"  METHOD. 

Of  more  than  passing  interest  for  the  past  15  years  has  been 
the  exploitation  of  extraction  in  the  capsule,  by  extraocular  manip- 
ulation, under  the  name  of  the  "Indian  method";  and  in  the 
same  connection  one  is  accustomed  to  see  or  to  hear  the  name  of 
Major  Henry  Smith,  of  Jullundur,  Punjab,  India.  Herbert,  in  his 
most  excellent  work  on  Cataract  Extraction,  1908,.  p.  252,  says: 
"The  work  in  India  was  begun  by  Mulroney,  at  Amritsar  in  the 
Punjab,  in  i8(;o.  He  made  a  downward  section  without  iridectomy, 
and  exj)elled  the  lens  by  manipulation.  In  1893,  1,145  o^  these 
operations  were  performed  at  Amritsar.  Henry  Smith,  at  Jullundur, 
also  in  the  Punjab,  adopted  the  method,  but  preferably  with  an 
upper  section,  and  laterly  with  iridectomy.  Obtaining  better  results, 
he  has  expanded  the  work  greatly.  Now  the  extractions  at  Jullun- 
dur number  about  three  thousand  ])er  annum.  According  to  .Arnold 
Knapp,  the  oi)eraling  season  at  Jullundur  comprises  onlv  6  weeks 
si)ring  and  autumn,  about  t,ooo  extractions  occurring  in  the  spring 
and  2,000  in  the  fall — 42  days  for  2,000 — or  nearly  50  every  day. 
In  the  year  from  Alay  31,  1904,  to  May  31,  1905,  Smith  extracted 
2,616  cataracts  in  their  capsules,  and  only  151  with  capsulotomy. 


INDIAN    MKTIIOIJ 


571 


With  this  extraordinary  experience  he  has  clearly  and  authoritatively 
established  expression  as  the  correct  method  of  (kii\cring  the  lens 
in  its  capsule,  and  has  shown  that  it  is  applicable  to  the  large 
maiorilv  of  senile  cataracts." 


1 


\^ 


i 


K^ 


The  operation,  as  performed  by  Major  Smith,  gi\en  in  his  own 
words,  is  as  follows:  "An  incision  is  made  upward,  beginning  in 
the  corneo-scleral  junction  and  ending  well  within  the  cornea.  It 
includes  a  little  less  than  half  the  circumference  of  the  sclero-cornea. 
I  personally  prefer  the  incision  finished  in  the  cornea  without  a 
conjunctival  flap,  as  the  flap  is  more  or  less  in  the  way.     An  iri- 


572  EXTRACTION  OF  CATARACT 

(Icctomy  may  or  may  not  be  done,  according  to  the  operator's  fancy. 
The  speculum  is  now  removed,  the  assistant  draws  down  the  lower 
eyelid,  with  the  face  of  his  thumb  placed  on  the  skin  below  it;  with 
his  other  hand  he  lifts  the  upper  eyelid  forward  with  a  large-sized 
strabismus  hook  (Fig.  299),  in  his  lirst  three  fingers,  as  if  he  were 
lifting  the  contents  of  the  orbit  out  of  the  socket,  and  not  lifting  it 
toward  the  brow,  using  the  ring  and  little  finger  of  the  same  hand  to 
draw  back  the  brow  and  orbicularis  muscle.  This  does  not  imply 
any  violence  on  the  part  of  the  assistant. 

"The  operator  now  places  the  end  of  a  large-sized  ophthalmic 
spatula  (Fig.  300),  on  the  left  side  of  the  cornea  over  the  junction 
of  the  middle  and  lower  third  of  the  lens.  He  places  the  end  of  a 
large-sized  blunt-pointed  strabismus  hook  over  the  corresponding 
position  to  the  right  of  the  spatula  (Fig.  301).  He  makes  steady 
pressure  backward  toward  the  optic  nerve  with  this  spatula,  and 
he  makes  similar  pressure  with  the  strabismus  hook  except  that 
in  making  pressure  with  his  strabismus  hook  he  draws  it  backward 
and  forward  across  the  cornea.  The  edge  of  the  lens  at  the  wound 
will  be  seen  to  tilt  forward  and  the  clear  vitreous  will  be  seen  be- 
tween it  and  the  scleral  margin  of  the  wound.  As  soon  as  this 
occurs,  the  pressure  with  the  spatula  should  practically  cease  and 
the  same  stroking  movement  of  the  strabismus  hook  should  be 
continued,  its  position  not  being  altered  on  the  cornea  at  first,  but 
the  direction  of  the  pressure  exerted  through  it  should  be  altered 
gradually  more  and  more  in  the  direction  of  the  wound  until  it 
hnally  folds  the  cornea  beneath  the  lens;  at  this  stage  the  lens  is 
delivered.  The  iris  should  be  replaced  if  prolapsed.  The  assistant 
should  then  let  go  the  eyelid,  and  the  patient's  eye  should  be 
dressed  up. 

"I  may  here  state  that  my  experience  now  extends  to  about  20,000 
cataract  extractions,  about  17,000  of  which  have  been  in  the  capsule, 
and  amongst  the  latter  have  been  many  immature  cataracts, 
especially  in  recent  years." 

Major  Smith  lays  great  stress  on  two  points,  viz.,  that  the  pressure 
be  gradually  a[)plicd,  and  that  plenty  of  time  be  allowed  in  delivering 
the  lens.  If  the  first  point  is  not  observed  the  capsule  is  apt  to 
burst,  and  neglect  of  the  second  is  sure  to  result  in  loss  of  vitreous 
or  other  complication.  "The  pressure  exerted  is  moderate,  slow 
and  continuous,  gradually  relaxing  in  amount,  as  the  lens  is  seen  to 
be  well  on  its  outward  way.     The  process  must  be  done  slower,. 


INDIAN    METHOD  573 

and  with  much  more  deliberation  than  in  the  capsule  laceration 
operation.  The  continued  pressure  quickly  tires  out  the  iris,  which 
dilates  and  allows  the  lens  to  emerge  very  like  the  process  of  jjar- 
turition.  If  the  expression  be  attempted  rapidly,  the  capsule  will 
probably  burst  just  as  it  is  coming  out.  If  this  accident  does 
happen,  it  is  best  to  keep  up  the  pressure  with  the  hook,  so  that  the 
capsule  does  not  retract,  and  try  and  gently  drag  it  out  with  a  pair 
of  ordinary  dissecting  forceps  applied  to  the  part  outside  the  wound. 
The  broad  hold  so  secured  will  often  succeed  in  drawing  out  the 
whole  of  it  with  its  contained  lens  matter." 

"  When  the  lens  is  halfway  out  .  .  .  a  clear  point  of  vitreous  will 
occasionally  appear  in  the  wound  behind  the  lens.  .  .  .  The  spoon 
in  the  left  hand  .  .  .  should  be  pushed  beneath  the  lens  through 
the  clear  point  and  the  lens  suspended  on  it.  Once  the  lens  is 
supported  on  the  spoon  the  strabismus  hook  can  be  used  as  before 
to  drive  out  the  lens,  the  spoon  merely  coming  with  the  lens,  but 
not  drawing  it  out.  ...  If  we  attempt  to  lift  out  the  lens  on  the  spoon 
merely,  the  capsule  will  give  away  with  exceeding  frequency." 

"In  addition  to  this  occasional  insertion  of  the  spoon,  the  iris 
forceps  have  sometimes  to  be  introduced  to  seize  ruptured  capsule. 
If  the  capsule  has  retracted,  we  should  try  by  gentle  stroking  to 
press  out  its  contained  lens  matter,  .  .  .  and  if  the  capsule  be  evi- 
dent to  the  eye,  we  may  make  an  attempt  to  catch  it  with  an  iris 
forceps  and  fetch  it  out.  Where  no  accident  occurs  the  only  instru- 
ment introduced  into  the  globe  is  the  knife.  Ordinary  dissecting 
forceps  are  used  for  seizing  ruptured  capsule  lying  in  the  wound." 

In  consequence  of  Major  Smith's  reports  ophthalmic  surgeons  all 
over  the  civilized  world  have  been  emboldened  to  make  trial  of  his 
methods.  In  the  United  States  alone  the  number  of  his  would-be 
imitators  has  been  a  large  one.  Some  six  or  eight  of  our  countrymen 
have  made  the  journey  to  India  that  they  might  study  the  mode  of 
procedure  first-hand.  The  last  of  these  is  Dr.  W.  A.  Fisher,  of 
Chicago,  who,  having  just  returned,  read  a  paper  before  the  Chicago 
Ophthalmological  Society  on  February  i6,  1914,  describing  his  con- 
ception of  the  technic  of  the  operation.  Dr.  Fisher  has,  since  his 
return,  in  a  number  of  instances,  very  skillfully  demonstrated  the 
operation.  The  writer  has  seen  him  operate  and  has  also  observed 
a  few  of  the  cases  thus  operated.  That  the  technic  of  the  measure, 
particularly  with  rcsi)ect  to  escape  of  vitreous,  has  been  of  late 
somewhat  improved,   there  is  no  doubt.     But  so  also  has  that  for 


574  EXTRACTION    OF    CATARACT 

simple  uxtraclion  and  discission  of  after-cataract.  Indeed,  the  chief 
improvements  in  the  Indian  operation  may  be  equally  applied  to 
simple  extraction.  As  the  latter  operation  is  performed  to-day,  that 
is,  with  section  well  down  at  the  base  of  the  cornea,  ending  with  a 
conjunctival  flap,  with  or  without  peripheral  incision  of  the  iris, 
with  the  improved  methods  for  the  removal  of  cortex  and  of  after- 
treatment,  ophthalmic  surgeons  all  over  the  world  are  making  series 
of  simple  extraction,  well  up  into  the  hundreds,  without  a  single  un- 
toward accident,  either  immediate  or  consecutive.  Supposing  that 
50  per  cent,  of  them  require  discission  of  secondary  cataract,  what 
of  it?  Patients  submit  most  willingly  to  the  measure,  are  but  slightly 
inconvenienced  by  it,  and  if  done  after  the  manner  described  on  page 
585,  this  operation  is  safe  and  sure. 

It  may  be  added  that  immature  cataracts  are  no  longer  taboo  with 
respect  to  simple  extraction.  And  if  the  preliminary  capsulotomy  of 
Homer  Smith  be  employed,  partial  cataract,  at  any  stage,  may  be 
safely  extracted,  leaving  no  cortical  remains. 

As  compared  with  the  foregoing  what  is  the  present  status  of  the 
Indian  operation  ? 

1.  The  Incision, — It  necessitates  a  very  extensive,  wholly 
corneal  section,  conducive  to  slow  healing,  iris  incarceration,  imper- 
fect coaptation  and  cicatricial  distortion  of  the  corneal  curvature. 

2.  The  Excision  of  the  Iris. — ^An  enormous  iridectomy  is  made, 
which  leads  to  numerous  iris  complications,  and  even  to  secondary 
glaucoma.  The  material  value  of  a  round  movable  pupil  cannot  be 
overestimated,  for  the  reasons  stated  on  page  548.  Aside  from  these 
considerations  the  cosmetic  effect  of  such  a  pupil  is,  by  no  means,  to 
be  ignored;  whereas,  the  appearance  of  the  eye  after  an  Indian 
extraction  is  anything  but  beautiful. 

In  the  majority  of  the  cases  I  have  observed  after  the  intracapsular 
extraction — and  they  include  those  operated  according  to  the  latest 
technic — the  reaction  has  been  excessive.  Irido-cyclitis  has  been 
almost  the  rule.  Nor,  singularly  enough,  have  they  been  free  from 
membranous  pupillary  obstructions. 

.;.  The  High  Percentage  of  Vitreous  Loss. —Notwithstanding 
the  imjjrovenu'nt  in  technic  this  remains  one  of  the  chief  objections 
to  extraction  of  ihe  encai)sule(i  lens,  and  the  one  that  will  i)robably 
forever  prevent  its  adoption  as  a  routine  measure.  Moreover,  it  is 
to  this  great  drawback  that  some  of  the  others  here  enumerated  owe 
their  origin.     'I"hc  (h'rt'  ronse(|uences  directly  and  indircctlv  traceable 


INDIAN   MK'inoi)  575 

to  this  accident  ha\c  already  hccn  treated  of  under  "accidents, 
immediate  and  consecutive."  They  include  expulsive  chcjroidul 
hemorrhage,  suppuration,  acute  iridocyclitis,  slow  and  prolonged 
uveitis,  all  classes  of  iris  complications,  hyalitis,  glaucoma,  detach- 
ment and  degenerations  of  the  choroid  and  of  the  retina.  Yet  it  is 
the  custom  of  advocates  of  intracapsular  extraction  to  belittle  this 
e\-il. 

4.  Rupture  of  Capsule. — Xo  matter  how  clever  the  operator,  he 
can  never  be  certain  of  delivering  the  lens  with  its  capsule  intact.  At 
the  hands  of  Major  Smith  himself  the  capsule  breaks  in  5  to  <S  ])er 
cent,  of  cases — at  those  of  others  in  16  per  cent,  and  ui)ward.  If, 
as  most  often  happens,  the  capsule  must  then  be  left  in  the  eye,  the 
conditions  are  worse  than  if  ordinary  extraction  had  been  chosen. 
For  it  must  be  remembered  that  the  rupture  occurs  in  most  in- 
stances when  the  cataract  is  nearly  delivered,  that  is,  when  the 
zonule  has  been  torn  away  from  its  supports,  thus  leaving  the 
capsule  free  to  get  into  the  corneal  wound.  This  leads  to  de- 
layed union.  It  is  likely,  too,  that  the  abandoned  capsule  contains 
cataract  matter,  and  the  whole  forms  a  crumpled  mass,  more  potent 
for  trouble,  perhaps,  than  the  smooth  encapsuled  cortex  remaining 
after  other  methods. 

5.  Toilet  Difficulties. — Ophthalmic  surgeons  are  ])ractically 
a  unit  as  to  the  great  Importance  of  a  finished  toilet  after  extraction. 
This  means  not  only  replacing  of  the  iris,  but  seeing  that  there  is 
nice  coaptation  of  the  lips  of  the  wound,  that  the  conjunctival  llap 
is  in  its  place,  and  that  there  are  no  shreds  of  fibrine  clinging  to  the 
incision.  And,  lasdy,  it  means  a  gentle  douching  of  the  conjunc- 
tival sac.  None  of  these  things  can  be  properly  done  if  vitreous  has 
escaped.  Even  in  the  more  successful  instances,  the  absence  of  the 
support  afforded  by  the  zonule  and  capsule,  together  with  the  large 
coloboma  and  the  extensive  incision,  make  it  risky  to  i)erform  a 
proper  toilet. 

6.  Technical  Difficulties.— That  the  operation  makes  greater 
demands  not  only  upon  one's  skill,  but  also  upon  one's  judgment, 
upon  the  sense  of  touch  and  upon  that  almost  intuitive  sense,  which, 
when  exercised  to  the  fullest,  is  so  much  to  be  relied  upon  in  averting 
disaster,  all  are  agreed.  Many  of  the  difficulties  hinge  upon  knowing 
how  much  pressure  is  required,  and  where  best  applied  to  loosen  the 
lens  or  the  zonule  from  its  attachments,  and  to  follow  it  uj)  in  the 
safest  and  surest  manner  till  the  cataract  is  delivered.     Several  have 


;76 


EXTRACTION    OF    CATARACT 


confessed  to  having,  on  occasion,  failed  to  deliver  the  lens,  notwith- 
standing an  ample  incision,  because  the  degree  of  pressure  required 
was  greater  than  they  dared  to  make;  so  they  desisted  and  had  re- 
course to  capsulotomy. 

When  the  time  arrives  that  the  average  operator  can  rid  the  eye 
at  once  of  cataract,  sub-capsular  cortex,  and  capsule  with  as  little 
ultimate  damage  to  the  integrity  of  the  organ  as  it  now  incurs  from 
the  best  chosen  of  other  methods,  opthalmic  surgery  will  have  made 
an  enormous  step  in  advance.  That  such  a  time  has  not  arrived 
no  one  can  deny,  and  few  ])crhaps  are  so  optimistic  as  to  believe 
that  it  is  near. 

Vacuum  Fixation  of  the  Lens  and  Flap  Suture  in  the  Extrac- 
tion of  a  Cataract  in  its  Capsule.  ^ — ^\'ard  H.  Hulen,  of  Houston. 
Texas,  has  devised  a  method  of  intracapsular  extraction,  and 
appropriate  a])])aratus,  that  deserve  consideration.  The  steps  are 
as  follows: 


Fig.  302. — Diagram  of  method  of  inserting  suture  in  conjunctival  flap. 


1.  The  usual  preparation  of  the  ]:)aticnt  and  eye  with  the  pre- 
liminary dilatation  of  the  pupil. 

2.  Cocain  and  e])incphrin  are  used  for  local  anesthesia  and 
blanching. 

3.  The  speculum  is  introduced  and  section  made  in  the  limbus, 
which  should  include  one-half  of  its  circumference,  and  raise  the 
con  jiiiutiva  above  ])tit  sloj)  short  of  severing  the  flap;  a  line  silk  suture 
is  introduced  as  shown  in  Fig.  302;  then  the  bridge  is  cut  with  one 
snip  of  the  scissors.      (See  dotted  line.) 

'  Oplitli.    Rii-.,  Drccinl.cr.    i„io. 


VACUUM    FIXATION 


577 


4.  Now  the  iridectomy  is  performed  if  a  ])reliminary  oiu-  has  not 
already  been  made;  a  preparatory  iridectomy  is  always  desirahk-. 

5.  The  s{)eculum  is  next  removed  and  if  hlood  in  the  anterior 
chamber  obscures  the  ])u])il  it  should  be  washed  out  w  ith  a  <,'entle 
stream  of  warm  saline  solution. 

6.  The  assistant  holds  the  upper  lid  with  a  lid  hook  and  controls 
the  lower  with  the  thumb  of  his  other  hand.  Under  no  circum- 
stances must  he  permit  pressure  on  the  j^dobe  until  the  eve  is  llnally 
closed;  the  patient  at  the  same  time  should  look  straight  ahead, 
never  doivn. 

7.  The  cup  of  the  vacuum  extractor  (.4,  Fig.  303)  is  introduced 
from  the  side  through  the  section  and  gently  placed  on  the  anterior 
capsule  over  the  center  of  the  lens.  If  the  pupillary  margin  is  every- 
where free  the  nurse  is  directed  to  turn  the  cock  at  the  gauge.  The 
vacuum  cup  will  then  grasp  the  cataract  most  rigidly.  Now  the  lens 
should  be  slightly  lifted  and  rotated  on  its  anteroposterior  axis  to 
sever  the  suspensary  ligament;  then  with  the  upper  edge  slightly 
advanced  the  cataract  in  its  capsule  is  slowly  and  gently  lifted  out 
through  the  pupil  and  section. 

8.  The  suture  is  immediately  tied.  Safe  from  the  loss  of  vitreous, 
we  may  now  replace  the  edges  of  the  coloboma  with  the  iris  repositor 
(introducing  it  on  each  side  of  the  knot)  and  ])erform  the  usual 
toilet  of  the  eye  without  apprehension. 

Particular  attention  is  directed  to  the  advantages  of  the  llaj) 
suture  tied  on  delivery  of  the  lens  in  all  cases  of  extraction  in  capsule. 

To  remove  a  cataract  in  its  capsule  it  has  been  necessary  to  either 
express  it  by  external  pressure-manipulation  sufficient  even  in  the 
hands  of  a  careful  operator  to  endanger  the  vitreous;  or  to  transfix 
the  lens  internally  with  forceps  or  a  sharp  instrument,  thus  nec- 
essarily wounding  the  capsule  and  thereby  possibly  freeing  the  lens 
and  defeating  the  \ery  purpose  of  the  method;  a  combination  of 
these  two  manipulations  courts  the  disadvantages  of  both  methods. 
Fixing  the  cataract  with  the  vacuum  cup  obtains  lirmer  control  of 
the  lens  than  can  be  done  otherwise  and  without  injury  to  the  cap- 
sule; it  also  dispenses  with  all  pressure  or  manipulati(m  to  extract 
the  lens.  With  vacuum  fixation  the  delivery  may  be  hastened  or 
retarded  as  desired,  and  the  section  may  even  be  "plugged"  with  the 
lens  should  occasion  require  it. 

As  regards  the  necessary  vacuum  apparatus  (Fig.  303)  but  little 
need  be  added  to  the  description  already  published.     The  cup,  if 


578 


EXTRACTION    OF    CATARACT 


correctly  made,  is  })ractically  no  additional  tax  on  the  corneal  section; 
the  cataract  fits  into  it  when  the  vacuum  is  connected,  so  that  to 
make  the  cu])  smaller  or  more  shallow  would  only  diminish  its 
"pulling  power."  The  silver  shank  is  malleable  but  it  would  be  a 
doubtful  improvement  to  bend  it  at  right  angles,  etc.,  as  an  interested 
friend  has  also  suggested.  There  need  be  no  embarrassment  in  the 
introduction  of  the  straight  shank  extractor  and  it  will  not  do  to 
endanger  the  lumen  by  unnecessary  angles.  It  is  important  to 
choose  a  tube  for  connecting  the  extractor  to  the  vacuum  which  is 
sufficiently  flexible  to  permit  any  desired  movements  in  introducing 


Fig.  303. — The  complete  vacuum  apparatus,  with  the  extractor. 


the  cup,  and  yet  it  must  be  rigid  enough  not  to  collapse  from  the 
greatest  vacuum  ])ressure  reciuired. 

It  is  a  problem  for  the  future  to  determine  the  precise  amount  of 
vacuum  for  the  fixation  of  cataracts  of  various  consistencies.  Too 
little  pressure  will  allow  the  lens  to  slip  from  the  grasp  of  the  cup, 
and  too  much  may  rupture  the  capsule  and  disintegrate  the  soft 
lens,  or  even  threaten  the  integrity  of  the  eye.  Hulen  exhausts  the 
bottle  until  his  gauge  registers  from  20  to  25.  This  has  been  safe 
and  sufficient  for  the  usual  senile  cataracts. 

A  larger  exi)erience  and   its  consideration  by  \arious  operators 


SUCTION   AMJ   core  iiixc; 


570 


should  dctcrmiiu'  the  fulurL'  ])l;ur  of  thi--  mctliod  in  ()])Inh;ihiiic 
sur<i;ery. 

Suction  or  Aspiration. ^Ncxt  to  rcclinalion  this  is  the  most 
ancient  means  of  rid(Hng  the  eye  of  cataract,  thouf,di  aiJpHcable  only 
to  the  softer  kinds.  It  is  said  to  have  been  j^ractiscd  in  some  of  the 
Asiatic  countries,  as  Persia,  in  very  remote  times,  while  it  is  certain 
that  the  Arabians  employed  it  early  in  the  Middle  Ages.  It  con- 
sisted originally  in  introducing  a  hollow  needle  through  the  sclera 
into  the  lens  and,  by  some  means  of  suction,  usually  the  mouth, 
evacuating  the  cataract.  At  times  a  small  incision  was  hrst  made 
through  which  to  pass  the  canula.  Early  in  the  past  century  it 
had  found  favor  in  the  eyes  of  the  Italian  surgeons,  one  of  whom, 
Pecchioli,  improved  on  the  older  method  by  first  making  keratonyxis 
(discission)  and  after  the  lens  matter  was  well  broken  up,  inserting 
a  hollow  needle  and  aspirating.  In  England,  during  the  early 
sixties,  the  operation,  for  a  few  years,  numbered  among  its  prose- 
lytes such  distinguished  men  as  Teale,  Lawson,  and  even  Bowman. 
The  last-mentioned  invented  an  aspirator  for  the  purpose  (Snellen). 

The  last  revivals  of  it  were  in  Brussels,  Belgium,  about  1875,  by 
Coppez  and  by  Redard,  the  latter  of  whom,  as  recently  as  1887, 
devised  an  aspirator  which  did  away  with  the  reversed  syringe,  as  the 
suction  engine,  reverting,  in  this  particular,  to  the  ancient  type  and 
substituting  the  mouth.  By  its  advocates  the  method  was  deemed 
proper  for  just  the  class  of  cataracts  for  whose  removal  the  surgeons 
of  to-day  make  either  discission  or  linear  extraction,  viz.,  recent  trau- 
matic cataracts,  the  yet  unexplained  soft  cataracts  of  young  children, 
and  those  that  occur  spontaneously  in  adults  under  middle  life. 

Couching,  depression,  reclination,  displacement,  abaisse- 
ment,  are  all  terms  used  to  denote  the  most  ancient  form  of  cataract 
operation — so  ancient,  indeed,  that  the  tracing  of  its  origin  is  lost 
in  the  remotest  antiquity.  It  may  be  mentioned  that  \\'illl)urg,  of 
Nuremberg,  had  in  the  year  1785  advised  a  form  of  reclination  and 
depression,  which  was  to  turn  the  lens  straight  over  backward,  the 
hinge  being  directly  below  so  that  it  rested,  anterior  surface  up- 
ward, on  the  lowest  segment  of  the  ciliary  body.  There  were  two 
methods  of  making  the  ancient  operation — one  by  introducing  a 
thorn  or  other  needle-like  instrument  through  the  center  of  the 
lower  segment  of  the  cornea  {keratonyxis)  obliquely  upward  through 
the  pupil  into  the  middle  of  the  upper  segment  of  the  crystalline, 
elevating  the  handle,  with  the  cornea  for  a  fulcrum,  and  thus  forcing 


:^8o  EXTRACTION    OF    CATARACT 

the  cularacl  dirccily  clown,  wilhoul  turning  it,  between  vitreous  and 
ciliarv  bodv.  'I'he  other  accom])lishcd  the  same  result,  but  the 
instruincnl  was  ihrusl  into  the  lens  through  the  sclera  {sderonyxis) 
near  ihe  horizontal  meridian,  ^ix  or  eight  millimeters  back  of  the 
scdero-corneal  junction.  Wilburg  ])unctured  the  sclera  in  the 
horizontal  meridian,  and  four  or  hve  millimeters  from  the  limbus, 
with  a  flat  needle  which  he  guided  between  the  iris  and  capsule, 
preferring  rather  to  hug  or  even  to  tear  the  latter,  in  order  to  avoid 
the  iris.  He  then  applied  the  flat  of  the  needle  to  the  front  of  the 
lens,  above  its  middle,  and  tipped  it  over  backward. 

Depression,  discission,  and  suction  remained  the  only  surgical 
measures  ever  undertaken  for  the  relief  of  blindness  from  opacity 
of  the  crvstall  ne  until  Daviel  hit  upon  a  better.  Yet,  strange  to 
relate,  after  more  than  fifty  years,  the  progress  of  the  operation  for 
extraction  had  been  so  slight  that  in  the  last  years  of  the  i8th  and 
the  early  years  of  the  19th  century  this  primitive  method  of  depres- 
sion had  staunch  defenders  among  the  most  renowned  ophthalmic 
surgeons     Richter,  de  Wenzel,  and  Beer. 

During  the  first  decade  (1803)  of  the  last  century,  Scarpa  gave  a 
fresh  iminilse  to  its  popularity  by  so  modifying  the  operation  as 
to  turn  the  cataract  downward  and  outward,  so  that  it  lay  with  its 
anterior  surface  inward  and  its  posterior  against  the  infero-temporal 
portion  of  the  ciliary  body  (true  reclination),  instead  of  pushing  it 
straight  down  into  the  vitreous  (true  depression),  as  his  predecessors 
had  done. 

The  last  of  the  great  champions  were  Sichel  and  Desmarres, 
beside  many  others  of  lesser  fame.  Not  because  they  lacked 
j)ersonal  knowledge  or  experience  with  the  discovery  of  Daviel — 
for  they  had.  for  the  most  part,  labored  faithfully  and  perseveringly 
to  give  it  the  precedence  it  deserved — but  for  the  reason  that  the 
immediate  results  of  the  ])r()cedure  were  disheartening.  They 
naturalh'  returned  to  the  method  by  whicli  they  were  spared  the 
oft-recurring  \isitations  of  su])puration  — that  incubus  of  the  earlier 
eye-surgeons — notwithstanding  the  fact  that  tlie  ultimate  benefits 
were  even  then  \astl\'  in  fa\(>r  of  extraction.  I^'or,  sooner  or  later, 
most  of  the  lenses  dislocated  into  the  \itreous  caused  serious  dis- 
turbance, detachment  of  the  retina,  \arious  forms  of  uveitis,  etc., 
or  the  sight  rrstorc'd  l>y  the  operation  was  sul)se(|uently  lost  again 
by  the  rea|)pearancc'  of  tlu'  calarnct  at  its  normal  site-not  an  in- 
fretpient  excnt. 


coucnixG  581 

Since,  in  the  o])ini()n  of  certain  ()|)hlhalinic  surgeons,  llie  ()j)erali()n 
of  reclinalion,  or  couching,  is  not  alloj^elher  obsolete,  a  description 
of  the  most  recent  mode  of  performing  it — that  of  Scarpa — may  not 
be  amiss. 

The  following  instruments  arc  required;  blepharostat,  lixalion 
forceps  and  a  stop-needle  similar  lo  Bowman's,  only  slightly  curved 
on  the  ilat,  the  distance  from  the  point  to  the  shoulder,  or  sloj), 
being  about  one  centimeter.  According  to  usage,  the  surgeon 
and  ])alient  ithe  latter  witli  |ni])il  dilated)  sit  facing  each  other, 
though  there  is  no  good  reason  why  an  operating-table  should 
not  be  used.  The  lids  are  i)ropped  open,  the  globe  is  steadied  in  the 
usual  way,  and  the  needle,  witli  its  con\-exity  directed  u])ward.  is 
entered  at  the  temporal  side,  four  millimeters  back  of  the  sclero- 
corneal  junction,  and  very  slightly  below  the  horizontal  meridian. 
Thus,  the  long  axis  of  the  wound  is  placed  in  a  meridian  of  longitude, 
insuring  the  minimum  of  traumatism  to  the  ciliary  zone.  As  soon  as 
the  spear  portion  has  entered  completely  the  ])osterior  chamber, 
the  convexity  of  the  shaft  is  turned  forward,  the  instrument  pushed 
inward,  either  between  the  posterior  surface  of  the  iris,  or,  which 
would  be  more  likely — seeing  the  space  is  nil  or  very  slight — 
beneath  or  through  the  anterior  capsule  itself.  Then  on  until  the 
point  nears  the  inner  border  of  the  pupil,  somewhat  above  the  center, 
or  until  the  stop  touches  the  sclera.  Holding  the  stop  firmly  against 
the  sclera,  as  a  fulcrum,  a  movement  of  the  handle  is  made  whereby 
the  cataract  is  swung  out  and  down  so  as  to  rest  with  its  posterior 
surface  between  the  insertion  of  the  external  and  that  of  the  inferior 
rectus. 

Having  pressed  the  cataract  lightly  down  against  the  ciliary  body 
and  choroid,  it  is  held  so  for  a  few  moments,  the  better  to  insure  its 
remaining  there,  the  movement  of  the  handle  is  reversed  and  the 
convexity  of  the  needle  brought  back  against  the  iris,  when  a  pause 
is  made  lest  the  lens  bob  up  and  have  to  be  depressed  a  second  time. 
The  quarter  turn  is  made  to  again  put  the  convexity  upward,  when 
the  instrument  is  withdrawn  in  the  same  position  as  when  introduced. 
Among  the  immediate  accidents  of  the  operation  were  dislocation 
into  the  anterior  chamber,  the  breaking  up  of  the  lens,  and  the 
entanglement  of  the  needle  in  iris  or  nucleus  of  the  cataract. 

When  the  first  fruits  of  the  labor  of  v.  Graefe  and  his  disciples 
with  the  linear  method  became  apparent,  the  day  of  reclination  began 
to  decline.     It  grew  darker  and  darker  with  the  perfection  of  the 


582  EXTRACTION  OF  CATARACT 

flap  extraction,  and  it  was  totally  eclipsed  in  Europe  and  America 
by  the  advent  of  aseptic  surgery.  It  is  still  extensively  practised  by 
native  surgeons  in  several  of  the  Asiatic  countries. 

Captain  Henry  Smith  ^  reports  having  extracted  sixty-nine 
cataracts  from  the  eyes  of  natives  of  India  that  had  formerly  been 
couched  and  afterward  rose  to  obstruct  the  pupil.  One  could 
imagine  circumstances  under  which  the  operation  would  still  be 
admissible. 

Discission. — This  operation,  which  consists  in  puncturing  or 
cutting  the  lens  with  a  needle  or  a  small  knife,  like  that  of  depression, 
is  also  of  very  ancient  origin,  and  was  mentioned  by  Galen  as 
having  been  practised  by  the  "ancients."  Indeed,  the  idea  was 
but  the  natural  outcome  of  the  displacement  measure,  seeing  that 
in  case  the  lens  matter  was  liquid,  or  only  semisolid,  and  the 
depression  needle  entered  the  capsule — which  by  design  or  accident 
often  happened — the  cataract  would  disappear  by  absorption. 
Hence  acupuncture  would,  as  it  really  did,  become  the  logical 
treatment  for  those  soft  cataracts  that  were  not  suitable  for 
depression. 

Ambrose  Pare  gave  new  life  to  the  operation,  calling  it  sderotico- 
puncture,  for  the  needle  w^as  introduced  by  way  of  the  sclera  until 
1797,  when  Conradi,-  a  pupil  of  Richter,  devised  the  modern  route 
through  the  cornea,  and,  under  the  name  keratomyxis,  the  operation 
became  general.  Langenbeck^  was  the  first  to  employ  a  mydriatic — 
belladonna — in  this  connection,  which  greatly  facilitated  matters. 
The  sphere  of  the  operation  is  at  the  present  time  limited  to  soft 
lenses,  such  as  the  recent  or  undegenerated  traumatic  and  all  the 
cortical  cataracts  of  young  or  relatively  young  subjects,  the  trans- 
parent lenses  of  high  myopia,  those  congenitally  displaced,  and, 
in  a  somewhat  modified  form,  to  secondary  or  after-cataract.  The 
operation  also  has  a  small  field  of  usefulness  for  congenital  zonular 
or  lamellar  cataracts  in  children  and  young  adults.  It  may  be 
stated,  in  passing,  that  the  surgical  treatment  of  these  cases  is  not 
attended  with  the  same  degree  of  satisfaction  as  that  of  other 
varieties.  If  the  zone  of  opacity  is  small,  not  larger  than  a  good- 
sized  pupil,  the  best  operation  is  optical  iridectomy,  preferably 
inward  and  slightly  downward.  It  is  only  when  the  area  of  the 
cataractous  circle  is  large  that  a  lens  operation  is  to  be  considered. 

1  Ind.  Med.  Gaz.,  xxxvi,  p.  224. 

2  Arnemann's  Magazine,  1797,  i,  p.  61. 

3C.  J.  M.  Lungenbeck,  Bibl.  f.  Chirurgie,  i8oq. 


DISCISSION  583 

Then  it  becomes  a  clioice  belween  one  of  ihc  forms  of  exlraetion 
and  discission.  For  ni}'  j)arl,  1  prefer  the  latter,  allliout^h  it  may 
mean  three  to  five  repetitions,  the  last  of  which  is  usually  a  dilacer- 
ation  of  dense  membrane. 

The  time  of  life  beyond  which  discission  of  cataract,  that  would 
appear  to  be  moderately  soft,  is  impracticable  has  not  been  definitely 
decided  upon.  Certain  it  is,  however,  that  the  aii;e  once  fixed  as 
the  limit  has  been  more  than  doubled.  Knapp'  mentions  having 
made  the  operation  with  success  in  the  eyes  of  persons  thirty-seven. 
The  case  cited  below,  in  which  discission  was  made  for  high  myopia, 
is  a  shining  example  of  its  feasibility  at  Ihirty-hve  and  thirty-six. 

Mrs.  J.  K.,  age  27,  Jewess.  Seen  first  Jan.  5,  1892.  High  myopia, 
right;  high  myopic  and  astigmatism,  left.  Had  been  cured  of  trachoma 
and  vascular  keratitis.  Conical  cornea  in  both  eyes.  R.  V.  =  2/200; 
20/100+  I  w  — 20  D.  L.  V.  =  s/200;  20/100  +  I  w  —15  s  o  —  5  cyl. 
ax  135°.  Under  atropin  the  following  lenses  were  prescribed :  Right  — 18 
D;  Left,  — 15  s  O—  5  cyl.  ax,  135°.  Saw  patient  no  more  until  Nov.  14, 
1899.  Age  now  35.  Test  then  showed; — R.  V.  =  2/200;  20/100  w  —  25 
D;  L.  V.  =  4/200;  20/100  +  w  — 20  s  O  —  3  cyl.  ax  150°.  Advised  dis- 
cission which  was  done  in  the  right  eye,  Dec.  15,  1899. 

The  first  operation  consisted  in  a  mere  pricking  of  the  anterior  capsule. 
Little  or  no  effect.  One  week  later  a  bolder  discission.  Lens  slowly 
disappeared.  To  be  brief,  the  first  or  slight  operation  on  the  left  eye  was 
made  Oct.  11,  1900.  The  patient  was  now  36  years  old.  By  Feb.  i,  1901, 
the  lens  had  entirely  disappeared.  The  remarkable  features  of  the  case 
are  the  prompt  absorption  of  the  lenses  following  the  second  of  thorough 
discissions  and  the  ultimate  refractive  and  visual  results,  which  in  Septem- 
ber of  1903,  were  as  follows:  Right  eye,  with  — 4  cyl.  ax  120°  V.  =  20/20 
+  4.  Left  eye,  with  — 2.5  so—  2.5  cyl.  ax  110°  V.  =  20/30  +  i.  For 
reading,  added  +3  and  +2.  The  corneal  cones,  in  consequence  of  the 
operations  and  the  prolonged  bandaging,  had  in  great  measure  subsided. 

Many  of  us  have  seen  ready  absorption  in  much  older  persons 
after  traumatism  of  the  lens.  A  striking  instance  once  came 
under  my  observation.  A  machinist,  aged  49,  was  struck  in  the  eye 
by  a  flying  chip  of  brass.  The  man  came  immediately  for  treatment. 
A  thin  sliver  of  the  metal  was  seen  with  its  proximal  extremity  within 
the  anterior  chamber  and  its  distal  buried  deeply  in  the  crystalline. 
It  was  removed  through  the  enlarged  corneal  wound.  Absorption 
of  the  resulting  cataract  was  affected  in  an  incredibly  short  space 
of  time,  and  good  sight  was  restored  to  the  eye. 

In  my  service  at  the  Illinois  Eye  and  Ear  Infirmary,  about  two 
years  ago,  I  made  discission  for  cataract  in  case  of  a  woman  past 
45 — first  upon  one  eye,  then  upon  the  other.  The  first  cataract 
disappeared  promptly.  The  loosened  hard  nucleus  of  the  second 
fell  into  the  anterior  chamber  causing  some  irritation,   and  was 

1  Norris  and  Oliver's  "System,"  vol.  iii,  p.  811. 


584 


EXTKACTION    OF    CATARACT 


extracted  through  a  small  linear  (lance)   incision  by  means  of  a 
sharp  hook.     The  result  was  perfect  in  both  eyes. 

True,  after  the  disappearance  of  all  the  cortical  jjortion  of  the 
lens,  in  subjects  verging  on,  or  actually  in,  middle  life,  a  tiny  hard 
nucleus  may  occasionally  drop  down  either  behind  or  in  front 
of  the  iris,  and  there  become  the  source  of  considerable  irritation. 
But  this  can  be  easily  extracted  through  a  small  incision  with  the 
lance  keratome  by  means  of  the  open  sharp  hook.  Fortunately, 
these  dense  lens  remains  usually  fall  into  the  anterior  chamber, 
where  they  are  less  provocative  of  harm  and  whence  they  are 
extricablc  with  less  risk  and  difficulty  than  if  located  in  the  posterior 


Fig.   ^04. — Detail  of  discission. 


chamber.  In  the  latter  situation  even  a  small  nucleus  can  excite 
secondary  glaucoma,  as  I  ha\e  good  reason  to  know  by  recent  ex- 
perience with  such  an  instance  relative  to  a  thirty-year-old  man. 
In  the  event  of  the  nucleus  having  dropped  down  behind  the  iris  it 
might  be  got  into  the  anterior  chamber  by  placing  the  patient  on 
his  stomach  upon  an  operating-table,  with  the  head  hanging  over 
the  end  and  so  manipulating  and  jarring  it  as  to  cause  the  nucleus 
to  enter  the  front  cliambcr  by  gravity. 

These  fads,  together  wilh  llic  added  confidence  inspired  by  the 
use  of  the  (Iraefe  knife  and  ils  insertion  at  the  base  of  the  cornea, 


DISCISSION  5^5 

have  led  mc  of  laic  years  lo  make  discission   in  a  number  of  cases 
for  which  formerly  only  exlraclion  would  ha\e  been  thought  of. 

The  jj;reat  majority  of  operators  make  true  keratonyxis,  using 
some  form  of  needle  or  combination  of  needle  and  small  knife— 
Knai)p's  for  example — and  pierce  the  clear  cornea  two  or  three 
millimeters  from  the  limbus.  Following  the  most  worthy  examj^le 
of  H.  Pagenstecher,  the  writer  has  for  a  number  of  years,  and  with 
ever  increasing  gratification,  substituted  a  small  model  of  the 
Graefe  knife  for  the  needle,  and  instead  of  going  through  clear 
cornea,  enters  the  instrument  at  tlie  limbus  or  a  trille  back  of  it. 
The  following  will  suffice  for  a  description  of  the  operation  in 
general,  the  surgeon  making  his  choice  of  needle,  knife-needle,  or 
Graefe  knife. 

Operation.— The  pupil  having  been  previously  dilated,  the 
patient  is  placed  either  upon  an  o])erating-chair  or  upon  the  table. 
The  operator,  if  he  be  ambidextrous,  stands  behind  the  chair  or  at 
the  head  of  the  table  for  either  eye,  manipulating  the  knife  with 
the  hand  which  corresponds  to  the  eye  in  question.  Otherwise,  in 
operating  the  left  eye,  he  stands  on  that  side  with  his  own  left  side 
against  the  chair  or  table.  The  instruments  are  the  blepharostat, 
fixation  forceps  (without  a  catch)  and  a  Graefe  knife  whose  blade 
is  somewhat  smaller  than  that  of  the  average  or  regulation  pattern, 
and  very  sharp  both  as  to  point  and  edge.  Recently  at  the  Eye  and 
Ear  Infirmary,  while  speaking  of  the  requirements  of  the  knife  for 
discission,  one  of  the  internes,  Dr.  Fullenwider,  suggested  removing 
the  cutting  quality  of  the  blade,  save  for  the  part  to  be  actually 
engaged  in  the  capsule  and  lens.  The  idea  was  so  rational  that 
I  have  since  had  put  in  order,  for  this  purpose,  a  knife  whose  edge 
is  sharp  for  only  5  or  6  millimeters  from  the  ])oint.  With  this, 
w^ounding  of  the  iris  and  needless  cutting  of  the  base  of  the  cornea 
with  undue  escape  of  aqueous  are  avoided.  The  illumination  is 
either  daylight  or  artificial,  focused  on  the  eye  through  a  large  lens. 
A  drop  or  two  of  4%  cocain  solution  is  instilled,  and  after  a  wait  of 
five  minutes  the  blepharostat  is  put  in  i)lace,  the  eye  is  flooded 
with  warm  boric  acid  solution,  the  excess  of  which  is  sponged  away. 

A  good  firm  hold  is  taken  of  conjunctiva  and  episclera  with  the 
fixation  forceps  close  to  the  limbus  on  the  nasal  side;  the  knife  is 
made  to  perforate  the  cornea  (edge  toward  the  operator)  exactly  in 
the  outer  sclero-corneal  junction,  encroaching  even  on  the  con- 
junctiva, in  the  same  manner  as  in  making  the  puncture  for  flap 


586 


EXTRACTION    OF    CATARACT 


extraclion  (Fig.  304).  It  is  jnishcd  in,  following  the  plane  of  the 
corneal  base,  until  the  point  is  opposite  the  center  of  the  pupil,  when, 
if  it  be  the  first  discission  in  the  case,  the  handle  is  raised  and 
the  center  of  the  capsule  merely  punctured.  If  not  the  first,  the 
point  of  the  knife  is  made  to  swing  in  the  central  meridian  of  the 
lens  till  it  approaches  the  pupillary  margin  just  across  from  the 
operator — below  always  with  the  ambidexter — the  handle  elevated, 
and  the  blade  pushed  slantingly  into  the  lens  substance,  taking 
care  not  to  go  through  the  posterior  capsule.  The  handle  is  then 
rotated  away  from  the  operator  and  a  free  incision  is  made  in  the 


Fig.  305. — Discission. 

crystalline.  The  knife  is  now  once  more  ])ut  into  the  horizontal 
position,  as  on  entering,  and  ra})idly  withdrawn.  This  last  move 
would  better  be  a  quick  jerk  which  best  assures  what  is  most  de- 
sirable, viz.,  the  leaving  behind  of  acpieous,  shreds  of  capsule,  and 
particles  of  the  lens. 

Before  abandoning  the  needle  or  knife-needle  and  the  puncturing 
of  clear  cornea  in  making  this  operation,  I  had  come  to  regard  the 
operation  of  discission  as  being  quite  as  formidable  as  that  of  extrac- 


DISCISSION  587 

lion  ilM'lf,  whclliLT  undertaken  for  cataract  or  i)U])illary  membrane. 
Statistics  prove  that  it  is  really  a  dangerous  operation.  Hardly 
an  operator  of  fair  experience  but  has  had  at  some  time  very  serious 
reaction  follow  "a  simple  needling."  The  perils  incident  to  the 
ordinary  needle  operation  were  strongly  brought  out  and  emphasized 
by  the  well-known,  world-wide  inrjuiry  of  Landolt,  instituted  some 
years  ago. 

Since  adopting  the  minature  Graefc  knife,  prepared  as  described 
on  page  585,  and  the  extreme  peripheral  place  of  entry,  the  procedure 
has  to  me  lost  all  its  terrors,  and  1  no  longer  hesitate  to  make  as 
many  repetitions  of  it  as  are  needed  in  a  given  case.  The  reasons 
for  the  superiority  of  the  knife,  modified  as  stated  above,  are: 

1.  The  cross-section  of  a  properly  made  modern  modification  of 
the  Graefe  knife  is  an  ever-increasing  wedge  which,  while  entering 
without  a  jog,  effectively  keeps  back  the  aqueous. 

2.  It  cuts  better  than  the  needle  or  knife-needle,  both  of  which 
mostly  tear,  and  the  edged  portion,  having  some  length,  allows  more 
leeway,  i.e.,  the  blade  may  move  slightly  in  or  out,  yet  still  be 
enabled  to  cut  the  capsule.  Best  of  all,  it  permits  one  to  impart  to 
the  blade  that  delicate,  almost  imperceptible,  sawing  movement  so 
essential  to  incision— especially  desirable  with  membranous  cataracts. 

3.  All  the  trenchant  needles  have  round  shanks  whose  diameter 
is  smaller  than  is  the  width  of  the  blade,  making  a  sort  of  shoulder 
where  the  two  meet,  so  that  they  ream  out  a  hole  and  permit  the 
aqueous  to  escape.  This,  in  view  of  the  changed  character  of  the 
aqueous  that  is  secreted  after  sudden  evacuation  of  the  anterior 
chamber— i.e.,  that  it  is  much  richer  in  albuminoid  substances- 
renders  it  highly  desirable  that  there  be  no  escape  during  the 
operation.  With  the  method  in  question  one  is  able  to  make  a 
number  of  discissions,  both  for  primary  and  secondary  cataract, 
without  ever  losing  a  drop  of  aqueous.  Again,  the  trenchant 
needles  go  into  the  anterior  chamber  with  a  start  that  is  apt  to  carry 
them  too  far,  and  they  come  out  with  a  pop,  and  are  prone  to  pull 
bits  of  capsule  into  the  corneal  opening,  there  to  lie  inviting  in- 
fection and  preventing  healing. 

The  advantages  of  the  peripheral  point  of  entry,  or  conjunctival 
route  over  that  which  is  further  in,  arc: 

1.  It  lies  in  the  vascular  zone  where  closure  and  healing  are  im- 
mediate. 

2.  It    affords    the    opportunity    of    penetrating    the    cataract    or 


588  EXTRACTION  OF  CATARACT 

capsule  in  a  \ery  slantin,^  manner,  which  makes  the  act  of  cutting 
more  positive  and  makes  it  easy  to  avoid  going  through  the  posterior 
capsule  and  wounding  the  vitreous. 

If,  for  example,  one  wishes  to  cut  a  sheet  of  paper  with  a  knife, 
his  task  is  much  easier  if  lie  holds  the  blade  at  an  acute  angle  with 
the  plane  of  the  paper  than  if  held  at  or  near  a  right  angle. 

Bandaging  for  twenty-four  to  forty-eight  hours  after  the  operation, 
and  atropin  throughout  the  treatment,  constitute  about  all  the 
needed  after-measures  in  most  instances. 

It  is  desirable  that  the  knife  enter  by  a  rather  long  and  slanting 
wound  canal,  so  that  it  has  the  properties  of  a  valve-like  entrance. 
Thus  the  wound  may  clasp  the  knife  so  tightly  as  to  permit  of  the 
sawing  movement  by  the  mere  elasticity  of  the  globe,  i.e.,  without 
any  movement  of  the  knife  in  the  corneal  wound  itself.  ^Moreover, 
if  one  wishes  to  exchange  the  partly  dulled  blade  for  one  that  is  sharp 
throughout  its  whole  extent  it  is  easy  to  insert  the  latter  through  the 
original  wound  in  order  to  complete  the  section,  as,  e.g.,  to  make  an 
anterior  sclerotomy  after  having  divided  the  capsular  bands,  that 
constitute  the  discission,  as  in  secondary  cataract. 

ACCIDENTS  AND  COMPLICATIONS. 

Like  those  incident  to  extraction,  those  after  discission  are  both 
immediate  and  consecutive,  though  by  far  the  most  serious  pertain 
to  the  after  treatment. 

Among  the  more  frequent  immediate  accidents  are  wounding 
of  the  iris,  premature  escape  of  aqueous,  rupture  of  zonule  (disloca- 
tion) injury  to  the  ciliary  processes  by  tugging  and  tearing,  plunging 
the  instrument  into  the  vitreous,  and,  as  already  referred  to,  the 
dragging  of  portions  of  capsule  lens  or  vitreous  into  the  corneal 
wound.  The  best  means  of  avoiding  them,  while  in  the  main  quite 
obvious,  do  not,  e\-en  as  regards  the  most  skillful,  always  keep  them 
from  happening.  Perhaps  the  greatest  dcsideratiiiii  is  that  the  point 
and  edge  of  the  knife  be  as  sharp  as  it  is  possible  to  uia/cc  them. 

With  regard  to  the  consecutive  accidents — or  the  reactive 
processes — so  far  as  they  go,  lliey  are,  with  one  exception,  the  same 
as  follow  extraction,  being  iritis,  iridocyclitis,  and  ])us  infection,  ami 
require  the  same  treatment.  The  exception  alluded  to  is  glaucoma, 
caused  by  the  swelling  of  the  lens  matter  after  incision  of  a  soft 
cataract  or  of  the  trans])arent  crystalline.      If  the  subject  of  such  an 


SECONDARY    ( ATAkACT  589 

operation  is  under  :;o  )ears  of  age,  ihis  is  nol  an  uncommon  oc- 
currence. Hence,  in  ()])erating  for  the  first  time  in  a  <<iven  case, 
the  cut  in  the  caj)sule  should  be  purely  tentative  a  mere  j)rickin<^  of 
the  capsule.  Xe.xt  time,  there  havint^  been  no  special  reaction,  the 
effort  may  be  bolder.  Often  a  lens  will  rajiidly  disa])j)ear  from  a 
liny  i)unclure.  JUil  they  must  all  be  closely  watched,  and  at  the 
first  signs  of  high  tension  an  incision  made  with  the  keratome  and  as 
much  of  the  lens  matter  got  out  as  is  ])ractical)le,  holding  the  iris 
back  with  the  s])atula  as  indicated  (p.  567). 

Of  course,  eserin  may  be  tried,  but  unless  the  tension  subsides 
within  a  very  few  hours,  the  extraetion  must  he  made,  else  the  sight 
is  jeopardized.  If  the  patient  is  timid  or  nervous,  a  general 
anesthetic  would  better  be  administered  for  the  extraction,  as  the 
tension  and  hyperemia  are  bars  to  local  anesthesia.  The  conse- 
quences of  a  linear  extraction  are  not  nearly  so  much  to  be  dreaded 
as  a  few  days  of  secondary  glaucoma.  Fukala.  the  originator  of 
operations  upon  the  lens  for  high  myopia,  states  that  latterly  he 
makes  discission  in  these  cases,  expecting  later,  when  breaking  up 
and  swelling  of  the  crystalline  occurs,  to  make  extraction. 

Secondary  cataract,  after-cataract,  capsulo-lenticular  cata- 
ract, membranous  cataract,  all  refer  to  some  form  or  degree 
of  opacity,  occurring  in  the  pupil  after  the  lens  ])roi)er  has  disap- 
peared. It  may  be  the  result  of  accident  (traumatisln)  or  of  one 
of  the  surgical  measures,  extraction  or  discission.  The  first  are 
more  rarely  met  with,  the  second,  the  busy  ophthalmic  surgeon 
encounters  constantly,  and  it  is  to  these,  therefore,  that  this  chapter 
chiefly  relates. 

It  is  composed  of  varying  masses  of  encapsuled,  normal  or 
degenerated  lens  matter,  the  remains  of  the  lens  capsule,  more  or 
less  thickened  by  proliferation  of  its  endothelium,  and  particularly 
when  there  has  been  inflammatory  processes  in  connection  with  its 
formation,  the  addition  of  a  certain  amount  of  organized  plastic 
material.  Their  density  varies  from  that  of  a  web  .so  delicate  as  to 
be  invisible  by  ordinary  means  to  that  of  a  mat  so  thick  and  compact 
as  to  exclude  any  but  strong  light  from  the  depths  of  the  eye;  yet 
between  these  two  extremes  it  is  present,  to  a  degree,  in  practically 
all  eyes  after  removal  of  the  lens.  Even  the  extraction  of  the  lens 
in  its  capsule,  though  it  leads  less  often  to  secondary  oj)erations,  does 
not  do  away  with  them  altogether. 

When  one  considers  the  different  views  of  leading  eve  surgeons 


59°  EXTRACTION  OF  CATARACT 

as  to  the  relative  frequency  of  operable  secondary  cataract,  one  is 
at  a  loss  to  explain  their  great  disparity.  As  Panas  puts  it,  "  Between 
Knapp,  who  advises  discission  in  every  case  (after  extraction) ,  and 
Gayet,  who  intervenes  only  exceptionally,  one  must  know  how  to 
choose  a  golden  mean."  This,  however,  is  putting  it  rather  strong, 
for  Knapp  acknowledges  to  making  the  operation  in  only  70% 
of  cases.  The  degree  of  amblyopia  produced  by  the  after-cataract 
is  what  should  determine  whether  or  not  a  discission  be  made. 
Knapp  does  not  operate  if  the  visual  acuity  is  above  20/50.  Certainly, 
the  secondary  operation  is  called  for  if  the  vision  is  20/70  or  less 
in  consequence  of  the  membrane. 

As  has  already  been  stated,  the  principal  cause  of  secondary 
cataract,  at  least  of  the  kinds  that  call  for  operative  interference, 
are  abandoned  lens  masses  that  remain  adherent  to,  or  entangled  in, 
the  capsule  after  extraction,  and  are  specially  prone  to  follow  such 
operations  upon  unripe  cataracts.  Add  to  this  the  other  causes  of 
inflammation,  such  as  indiscriminate  laceration  of  the  capsule, 
bruising,  tearing  and  incarceration  of  the  iris,  and  we  have  not  much 
further  to  seek  for  the  origin  of  consecutive  membranous  cataract. 

Hypermature  and  sclerosed  cataracts,  although  they  sometimes 
present  certain  mechanical  difficulties  in  delivery  and  are  subject 
to  the  same  inflammatory  reactions,  expose  one  less  often  to  secondary 
cataract  than  the  forms  before  alluded  to.  Here  truly  an  ounce 
of  prevention  is  better  than  a  pound  of  cure.  Having  a  knowl- 
edge of  the  conditions  that  are  chiefly  instrumental  in  the  production 
of  secondary  cataract — as  well  as  of  the  fact  that,  notwithstanding 
the  greatest  skill  in  making  the  primary  operation  and  the  utmost 
care  in  the  after-treatment,  either  a  considerable  number  of  supple- 
mentary operations  or  some  grade  of  blindness  .is  inevitable — 
our  management  of  the  case  may  be  such  that  it  will  not  only  materi- 
ally diminish  the  chances  of  secondary  cataract,  but  it  will  also 
put  us  in  better  position  to  cope  with  it  when  it  does  occur  by 
leaving  the  eye  more  nearly  in  its  normal  state. 

As  to  the  length  of  time  that  should  elapse  between  the  extraction 
and  the  discission,  no  definite  period  can  be  fixed.  It  is  not  prudent, 
in  any  case,  to  interfere  while  there  are  any  remaining  traces  of 
irritation  from  the  primary  operation,  because  of  the  liability  of 
the  opening  in  the  membrane  to  speedily  close  again.  It  would 
be  well  to  wait  from  one  month  to  six  weeks  after  the  most  favorable 
recovery  from  the  extraction.     From  then  on  the  operation  may  be 


SECONDAKV    CATARACT  ^()l 

made  at  any  lime.  I'hen,  too,  there  is  j^reat  \ariation  in  llie  lime 
at  which  ihe  seconchiry  cataract  begins  to  <hill  ihe  sii^hl.  The 
latter  may  remain  good  for  several  months  or  even  several  years, 
then  fail  from  this  cause.  However  well-timed  the  "needling"  or 
successful,  it  does  not  insure  against  the  necessity  for  another  at 
a  later  date. 

There  are  several  surgical  measures  tliat  are  employed  to  free 
the  pupil  when  obstructed  in  this  manner,  and  the  choice  of  one  will 
depend  upon  the  character  of  the  membrane  in  c[uestion.  In  most 
instances,  it  will  be  some  kind  of  discission  or  incision,  seeing 
that  this  is  the  simplest  and  safest  means,  and  quite  as  elTectual 
as  any  for  the  usual  thin  variety  of  after-cataract.  Having  decided 
upon  discission,  then,  we  will  say,  what  sort  of  instrument 
shall  we  use  for  the  cutting  of  the  membrane?  For,  as  its  name 
implies,  the  operation  is  one  of  cutting,  not  tearing.  It  must  of 
necessity  have  a  trenchant  edge.  Now,  this  the  ordinary  spear- 
pointed  needle,  used  by  so  many  operators,  possesses,  it  is  true, 
but  in  a  very  limited  degree,  and  its  wound,  instead  of  being  a  clean 
incision,  is  a  jagged  rent.  One  of  the  knife-needles  is  a  far  more 
suitable  instrument,  and  Knapp's  is  the  best  of  these.  My  preference 
is  for  the  Graefe  knife,  selected  and  prepared  as  described  in  the 
chapter  on  Discission,  and  for  the  same  reasons  as  there  given. 
The  other  instruments  are  the  same  as  for  discission  in  general, 
viz.,  blepharostat  and  fixation  forceps. 

The  pupil  is  dilated  as  widely  as  possible.  The  illumination  of 
the  field  of  operation,  for  the  whiter  or  denser  membranes,  may  be 
bright  daylight,  but  for  the  thinner  or  less  conspicuous  ones  a 
stronger  is  required,  such  as  the  focusing  on  of  the  light  of  an 
Argand  burner  or  that  of  a  ground  incandescent  electric  bulb  by 
means  of  a  handglass.  Another  good  light  is  that  of  the  portable 
electric  bull's-eye  thrown  onto  the  eye  from  one  side  by  an  assistant. 
If  oblique  focal  illumination  is  employed,  the  assistant  must  be 
careful  not  to  focus  on  the  eye  a  sharp  image  of  the  flame,  but  to 
have  it  a  trifle  within  or  beyond  the  focusing  point,  as  this  gives  a 
more  even  and  a  larger  area  of  light.  Also  a  little  unsteadiness  will 
not  be  so  apt  to  cause  it  to  fail  the  operator  at  the  critical 
moment. 

The  eye,  the  instruments,  and  the  operator  all  having  been  as 
scrupulously  prepared  as  if  for  an  extraction,  excepting  that  only 
one  or  two  drops  of  4%  cocain  solution  are  required,  in  what  manner 


592  EXTRACTION  OF  CATARACT 

shall  the  membrane  be  divided?  According  to  the  principles  stated 
on  page  560,  the  knife  must  be  entered  at  the  limbus,  but  the  precise 
point  of  entry  must  be  governed  by  the  formation  of  the  membrane 
with  which  v^^e  have  to  deal — in  other  words,  by  the  position  and 
the  direction  of  the  denser  bands  which  compose  it,  for  these 
cataracts  arc  never  of  uniform  thickness  or  opacity  throughout.  It 
will  be  found  a  great  help  to  study  each  membrane  by  strong  focal 
illumination  and  a  magnifying  glass  or  with  the  ophthalmoscope 
and  transmitted  light  beforehand.  The  streaks  more  often  run 
crosswise  or  obliquely  than  vertically,  at  any  rate,  after  the  per- 
ipheral capsulotomy,  so  that  the  knife  is  best  inserted  at  some  place 
along  the  outer  corneal  limbus  farthest  from  the  ends  of  the 
more  prominent  bands  in  order  to  cut  athwart  them.  Here  it  is  of 
the  greatest  advantage  to  be  able  to  wield  the  knife  with  either  hand, 
as  should  the  ])ortion  about  which  one  is  most  concerned,  lie  hori- 
zontally and  near  the  upjjer  border  of  the  right  pupil  or  the  lower 
border  of  the  left,  it  could  be  more  easily  divided  and  with  less  risk 
of  injury  to  the  iris  and  ciliary  body  by  holding  the  knife  in  the  left 
hand.  Assuming  that  the  bulk  of  the  opacity  is  vertically  across 
the  center  of  the  right  pupil,  the  operator  stands  facing  the  top  of 
the  patient's  head  with  the  knife  in  the  right  hand  (edge  up),  and 
the  puncture  is  made  in  the  horizontal  meridian  at  the  limbus, 
and  precisely  as  if  for  extraction. 

The  point  is  pushed  in,  horizontally,  just  above  the  iris,  till  it  is 
opposite  the  center  of  the  pupil,  the  handle  is  rotated  in  the  horizon- 
tal plane  toward  the  operator  to  bring  the  edge  below  the  thicker 
bands,  or  the  back  of  the  blade  is  made  to  approach  the  lower 
pupillary  border.  The  handle  is  elevated  (in  the  vertical  plane) 
and  the  point  made  to  pierce  the  cataract  very  slantingly,  then  the 
handle  is  depressed  (in  the  horizontal  plane)  making  the  blade  cut 
upward  until  the  incision  nears  the  upper  pupillary  border,  when 
the  last  movement  of  the  handle  is  reversed,  to  bring  the  blade 
again  to  the  horizontal,  and  suddenly  withdrawn,  meanwhile  holding 
the  eye  very  firmly  with  the  forceps. 

The  elasticity  of  these  membranous  cataracts  is  sufficient,  in 
most  instances,  to  convert  the  incision  into  an  oval  opening.  ]\lore- 
over,  there  are  many  times  a  number  of  tiny  posterior  synechia 
so  that  the  mydriasis  produced  by  the  atropin  tends  also  to  stretch 
open  the  cut.  There  is  one  rather  singular  feature  relative  to  the 
bcha\i()r    of    the    meml)r;ine,    wliicli    is    occasionallv    shown    when 


J'OSTKRIOR    DISC  ISSION 


593 


engaged  by  ihc  edge  of  the  knife,  llial  it  is  well  to  hear  in  mind. 
Instead  of  dividing  at  once,  it  will  allow  itself  to  he  iiii>lied  along, 
doubled  o\er  the  edge,  and  seem  not  inclined  to  yield;  but  simply 
stop  the  j)rogress  of  the  knife.  Wait  for  a  moment,  and  the  severed 
bands  will  l)e  seen  to  fall  away  in  a  clean  incision.  Xo  decided 
sawing  is  needed.  Whether  it  is  the  fine  tremor  of  the  hand  which 
holds  the  knife  or  the  insensible  movement  of  the  eye,  .something 
acts  to  induce  this  fmal  ])arting.  As  before  staled,  however,  the 
smallest  of  sawing  motions  best  insures  a  prompt  and  smooth  incision, 
and  this  can  be  easily  and  safely  accomph'shed  with  the  knife  here 
employed. 

Now  and  then,  previous  to  extraction,  there  has  been  a  thickening 
of  the  central  portion  of  one  or  both  capsules,  and  the  ensuing 
secondary  cataract  is  not  of  the  kind  that  can  be  easily  incised, 
being  frailly  connected  with  the  zonule  and  most  resistant  just  wdiere 
the  cut  should  be  faultless.  The  same  is  true  of  that  \-ariety  of 
congenital  cataract  which  is  composed  of  a  mass  of  connecti\'e  tissue 
or  the  latter  mixed  with  chalk.  If  one  succeeds  in  the  discission, 
the  two  sides  are  apt  to  fall  together  again  and  reunite,  or  the  whole 
mass  is  merely  pushed  to  one  side  without  being  at  all  divided. 
It  afterward  drifts  back,  and  the  operation  counts  for  naught.  It 
often  happens,  however,  that  a  simple  discission  answers  perfectly 
in  just  such  a  case,  and  it  is,  perhaps,  best  to  make  at  least  one  trial 
of  this  method  before  resorting  to  a  more  complex  one. 

Posterior  Discission. — Much  has  been  said  concerning  this 
|)rocedure,  devised  some  years  ago  by  Da  Gama  Pinto,  of  Lisbon. 
It  consisted  in  incision  of  the  membranous  cataract  from  behind 
by  a  knife  passed  through  the  sclera.  The  method  has  had  few- 
supporters.  It  was  advocated,  however,  at  the  Lucerne  Con- 
gression  in  i(;o4  by  no  less  a  personage  than  De  Lapersonne,  suc- 
cessor to  Panas,  who  then  described  his  technic  and  a  special  knife  for 
the  operation.  At  the  same  meeting  Da  Gama  Pinto  himself  stated 
that  because  of  having  observed  two  cases  of  detachment  of  the 
retina  after  the  procedure,  he  had  abandoned  it,  and  had  returned 
to  the  anterior  method,  using  Knapp's  knife-needle. 

Arrachement. — Having  failed,  recourse  may  be  had  to  ])lucking 
out  or  tearing  out  (arrachement)  of  the  membrane.  This  usually 
consists  in  making,  first,  a  small  moderately  perii)heral  corneal  in- 
cision with  the  lance-knife,  inserting  thereat  a  pair  of  capsule 
forceps   and    pulling  out  the  thickened  membrane;  or  making  use 


594 


EXTRACTION    OF    CATARACT 


of  the  small  blunt  hook  and  proceeding  exactly  as  described  in  case 
of  the  congenital  cataract  cited  on  page  562. 

Extraction  of  Secondary  or  Membranous  Cataract. — It  is  a 

mistake  to  imagine  that  the  incision  here  should  be  as  extensive  as 
that  ordinarily  made  for  iridectomy.  Yet  many  ophthalmic  sur- 
geons use  a  keratome  of  the  regulation  breadth  for  this  operation. 
A  very  dense  membranous  cataract  can  be  readily  brought  out 
through  an  incision  three  or  four  millimeters  in  length.  Accordingly 
the  author  has  had  made  a  special  knife  for  this  procedure.  It  is 
double  edged  and  just  3  mm.  wide  where  the  edges  become  parallel. 
It  is  in  reality  only  a  modification  of  Agnew's  lance  keratome,  and 
the  operation  for  which   it  is  intended  is  identical  with  Agnew's 


Fig.  306. — Dilaceralion.     Keady  lo  pry  the  cataract  asunder. 


blunt  hook  extraction  described  elsewhere.  Puncture  is  made 
well  down  at  the  corneal  base,  the  point  is  pushed  across  the  pupil 
and  into  the  membrane  at  the  further  side.  The  knife  is  with- 
drawn, a  Tyrell  blunt  hook  is  inserted,  the  membrane  is  caught 
where  it  was  punctured  by  the  knife,  drawn  out,  and  if  need  be,  its 
hither  attachments  are  cut  off  with  scissors.  The  section  is  made 
with  greater  facility  and  precision  by  employing  such  a  knife 
than  in  the  case  with  the  lance  keratome. 

Dilaceration  has  for  its  end  the  creation  of  an  aperture  permeable 
to  the  rays  of  light  in  the  center  of  a  cataractous  pupil  by  rending 
and  prying  asunder  the  opposite  halves  of  the  obstruction.  It 
is  api)licable  lo  almost  any  of  the  thicker  secondary  cataracts,  but 


DILACKRATIOX  5(;5 

peculiarly  SO  lo  those  \ery  thick,  toui^h,  and  adlicriiit  ones  that  some- 
times follow  absorption  or  i)artial  absorption  of  the  lens  due  lo 
severe  injury;  as  also  to  those  that  come  after  oj^erations  for  primary 
cataract  that  have  been  attended  by  accidents  or  succeeded  by 
inllammatory  reaction.  The  chief  advantage  of  dilaceration  over 
discission  is  that  it  obviates  any  injury  to  the  ciliary  processes  from 
dragging. 

The  method  usually  employed  is  that  devised  by  Sir  William 
Bowman.  1  and  is  known  as  Bowman's  Double  Needle  Operaliou. 
The  instruments  are  lid  speculum,  fixation  forceps,  and  two  delicate 
sharp  stop-needles.  If  joossible,  the  pupil  is  dilated.  The  lids 
are  j)ropped  open,  the  eye  douched  with  warm  boric  acid  solution, 
the  globe  steadied  with  the  forceps,  held  in  the  left  hand,  and  one 
needle  passed  through  the  cornea,  in  the  horizontal  meridian, 
about  two  or  three  millimeters  from  the  limbus,  and  the  point 
pushed  into  the  center  of  the  cataract.  The  eye  is  now  steadied 
by  the  needle,  the  forceps  is  dispensed  with,  and  the  other  needle 
is  similarly  inserted  on  the  opposite  side  and  its  point  also  made 
to  enter  the  center  of  the  cataract.  If  the  two  needles  are  properly 
adjusted,  their  two  spear-shaped  blades  will  lie  flatwise,  one  against 
the  other,  in  the  horizontal  plane  of  the  eye.  (Fig.  306.)  Now  the 
two  handles  are  made  to  approach  each  other,  thus  separating  the 
points,  like  opening  the  blades  of  a  pair  of  scissors,  until  a  satisfactory 
orifice  is  torn  through  the  cataract.  A  pause  is  then  made  in  order 
to  fix  the  fragments,  then  the  first  movement  of  the  handles  is 
reversed,  and  they  are  withdrawn  in  the  same  sense  that  they  were 
entered.  The  distance  from  the  point  of  the  needle  to  the  shoulder 
or  stop  ought  not  to  be  so  great  as  to  allow  deep  wounding  and 
stirring  of  the  vitreous  for  fear  of  exciting  a  hyalitis.  Eight  milli- 
meters to  one  centimeter  is  ample,  and  twelve  milimeters,  which 
is  a  common  length,  is  too  great. 

The  after-treatment  of  discission,  arrachement,  and  dilaceration 
is,  as  a  rule,  neither  long  nor  eventful.  Immediately  the  operation 
is  completed,  the  eye  is  dressed  in  the  same  manner  as  after  extrac- 
tion. The  patient  maybe  permitted  to  walk  from  the  operating- 
table  to  his  room.  At  the  end  of  twenty-four  hours  the  eye  shoukl  be 
inspected,  and  if  all  signs  arc  propitious  at  the  end  of  forty-eight 
hours,  a  shade  or  medium  smoke  coquilles  may  be  substituted  for 
the  dressing.     It  is  wise  to  insist  that  the  patient  be  moderately 

1  Med.  Times  and  Gazette,  18:^2. 


59^  EXTRACTION    OF    CATARACT 

quiet  and  free  from  exposure  for  some  days  and  that  he  does  not 
pass  from  observation  under  ten  days  or  two  weeks. 

Division  with  Scissors. — There  will  always  be  a  small  class 
of  after-cataracts  to  confront  us  that  is  adapted  to  none  of  the 
methods  just  described.  Where  the  cataract  is  quite  dense  and 
attached  to  the  iris  or  where  the  pupil  is  much  misplaced  outward 
from  the  center  or  much  contracted.  In  fact,  the  conditions  are 
very  similar  to  those  that  call  for  iridotomy.  Here  some  form  of 
tiny  scissors  may  take  the  place  of  needle  or  knife.  This  necessitates 
the  making,  first,  of  a  fairly  extensive  corneal  section,  which  is  ac- 
complished much  in  the  same  manner  as  for  iridectomy,  the  difference 
being  that  it  is  desirable  to  make  a  small  opening  in  a  given  part  of 
the  cataract  at  the  same  time,  in  order  to  give  ingress  to  one  blade  of 
the  scissors.  When  it  is  not  practicable  to  utilize  the  kcratome 
n  this  way  one  must  ha^•e  recourse  to  scissors  ha^•ing  at  least  the 
under  blade  provided  with  a  keen  point  with  which  to  start  the  cut 
in  the  capsule.  The  corneal  incision  is  so  located  as  to  lie  parallel 
with,  and  accessible  to,  that  portion  of  the  membrane  which  is  to 
be  divided.  A  steep  puncture  is  made  with  the  lance  keratome 
in  the  exact  sclero-corneal  junction,  and,  if  possible,  the  opening  is 
made  in  the  cataract  with  the  same  forward  thrust  of  the  knife; 
when  not  jjossible  or  feasible,  the  blade  is  partly  withdrawn,  its 
point  j)laced  at  the  spot  for  the  ojjening,  and  again  pushed  forward. 
Having  failed  in  this,  the  sharp  blade  of  the  scissors  may  be  used.  In 
any  case  the  thinnest  part  of  the  cataract  is  chosen  for  the  opening. 
It  is  important  that  the  scissors  be  extremely  delicate  and  of  excep- 
tional sharpness.  De  Wecker's  ordinary  model  is  entirely  too  large. 
Those  shown  in  Plate  \TI,  No.  86,  are  suitable,  or  the  slraighter 
ones.  No.  85.  The  scissors  are  passed  into  the  anterior  chamber 
closed,  then  opened,  and  the  lower  blade  made  to  enter  or  to  cut 
the  opening  in  the  cataract,  and  to  further  divide  it  as  wished. 
If  cutting  in  a  single  direction  does  not  seem  to  give  a  sufficient 
pupil,  a  second  snip  may  be  made  diverging  from  the  same  point 
of  entrance  into  the  membrane,  or,  provided  the  original  opening 
in  the  ca])sule,  as  made  with  the  keratome,  is  long  enough,  two 
convergent  snips  may  be  made,  and  the  triangular  ])iece  tlius 
excised  be  extracted  with  the  iris  forceps  (see  Ruhnl's  and 
De  Wecker's  iridotomies).  Seeing  that  loss  of  vitreous  is  the  bug- 
bear of  this  operation,  the  .\ngelucci  fixation,  described  on  ])age  542, 
is  most  appropriate,  as  it  serves  effectually  to  fix  tlie  globe,  while. 


ARTIKICIAI.    RII'I:NI\(;  ^()-j 

at  the  same  linu',  il  lends  lo  hold  ilu'  corneal  wound  closed,  thus 
keeping  ])ack  ihe  \ilreous.  Any  one  of  ihe  four  recti  tendons  may 
be  grasped,  so  long  as  il  is  on  ihe  same  side  of  the  cornea  as  is  the 
location  of  the  keratoloniy.  It  is  essential  that  both  eye  of  patient 
and  hand  of  ()])eralor  be  ]>erfectly  steady. 

ARTIFICIAL   Ril'KXlXc;. 

The  extremely  slow  develo])menl  of  some  s])ecies  of  senile  cataract, 
especially  after  the  time  when  the  sight  has  become  greatly  interfered 
with,  has  always  been  a  source  of  grievance  to  which  both  j^atient 
and  surgeon  ha\e  l)een  victims.  Ks])ecially  is  this  true  of  certain 
incii)ient  nuclear  cataracts,  with  which  is  associated  a  high  degree 
of  amblyopia,  yet  hardly  any  visible  opacity,  even  of  the  lens  center, 
and  the  cortical  portion  is  perfectly  transparent.  Owing  to  the 
considerable  difference  between  the  index  of  refraction  of  these  two 
portions,  the  vision  may  be  reduced  to  the  counting  of  lingers  at  a 
distance  of  two  feet — barely  sufficient,  under  favorable  conditions, 
to  go  about  with,  yet  by  looking  in  with  the  oj)hthalmoscoi)e,  a 
fairly  bright  retlex  may  be  got  through  the  center  of  the  i)upil  with- 
out, however,  any  details  of  the  fundus.  But  with  the  pu])il  widely 
dilated  and  looking  through  the  periphery,  the  optic  nerve  and  the 
vessels  of  the  retina  can  be  defined  with  tolerable  clearness.  In 
other  words,  it  is  not  so  much  the  transmission  of  light  that  is  inter- 
fered with,  as  that  the  retinal  image  is  spoiled  by  diffraction.  This 
state  of  the  lens  may  persist  with  little  or  no  change  for  an  indefinite 
period.  Then  there  are  the  irregular  forms  of  cortical  cataract 
that  are  often  equally  tedious  and  troublesome. 

The  methods  employed  or  de\ised  to  hasten  the  ripening  of 
these  immature  cataracts  may  be  divided  into  four  groui)s: 

I.  Discission  of  anterior  or  posterior  capsule  or  of  both  anterior 
and  posterior  capsule  of  the  lens. 

II.  Massage,  either  indirect  through  the  cornea  (the  anterior 
chamber  ha\ing  been  evacuated),  or  dirccl  immedialelv  ui)on  the 
lens. 

III.  Intracapsular  injection  of  aqueous  humor,  normal  sail 
solution,  or  other  li(juid. 

IV.  The  External  Application  of  Heat  to  the  Eye. 

I.  As  early  as  1811,  (iibson,  of  London,  tried  discission  a  few 
days  pre\ious  to  the  linear  extraction  as  a  means  of  hastening  the 


598  EXTRACTION  OF  CATARACT 

maturity  of  cataracts  of  this  kind.  This  he  did  for  the  dual  purpose 
of  causing  rapid  opacifying  of  the  outer  cortex  and,  through  the 
entrance  of  the  aqueous  humor,  the  loosening  of  the  lens  substance 
from  its  capsule.  Muter,  in  1815,  resorted  to  similar  practice. 
On  account  of  the  subsequent  swelling  of  the  lens  and  the  generally 
unsatisfactory  extraction  which  followed,  the  procedure  was  not 
popularized;  although  forty  years  later,  in  1858,  Moren,  of  Heidel- 
berg, again  proposed  this  method  for  the  artificial  ri])ening  of 
cataracts. 

In  1864,  V.  Graefe^  endeavored  to  improve  upon  the  method  by 
making  three  operations  in  succession.  First,  an  upward  iridectomy. 
Second,  after  some  three  weeks,  a  crucial  opening  of  the  anterior 
capsule  with  Bowman's  needle.  Third,  after  several  days,  a  flap 
extraction.  His  aim  was  twofold — rapid  maturation  of  the  cataract 
and,  through  the  proliferation  of  the  endothelium  of  the  capsule, 
to  cause  a  loosening  from  it  of  the  cortex.  The  end  did  not  justify 
the  means. 

Twenty  years  after  the  introduction  of  the  v.  Graefe  operation, 
Stellwag,  in  1886,  proposed  the  discission  of  the  posterior  capsule 
by  means  of  a  scleral  puncture.  This  suggestion  was  modified  by 
Businelli  in  1888,  who  proposed  discission  of  both  anterior  and 
posterior  capsules. 

II.  Seventeen  years  after  v.  Graefe  modified  the  simple  discission 
for  maturation  of  cataract,  another  method  was  devised  by  Foerster,- 
of  Breslau,  which  had  a  host  of  imitators  and  modifiers  and  in- 
augurated a  veritable  boom  in  this  line.  This  surgeon  made  a 
preliminary  iridectomy  and  immediately,  while  the  anterior  chamber 
was  empty  and  the  crystalloid  was  in  contact  with  the  cornea, 
made  massage  through  the  latter  by  means  of  the  back  of  a  Graefe 
hard-rubber  spoon  or  the  heel  of  a  strabismus  hook;  then,  after 
a  few  weeks,  the  extraction. 

The  omission  of  the  iridectomy  and  indirect  massage  through  the 
cornea,  after  evacuating  the  anterior  chamber  by  means  of  a  simple 
puncture,  was  recommended  by  Meyer  at  the  Copenhagen  Congress 
in  1884.  In  1885,  direct  massage  of  the  lens  itself  was  advocated  by 
Rassander,  and  a  little  later  (1888)  Bettman,  of  Chicago,  performed 
a  similar  operation  with  an  instrument  of  his  own  design.  Direct 
massage  was  accomplished  by  following  the  paracentesis  with  the 

^  Archiv.  f.  Ophthal.,  x,  a.  2,  S.  20Q. 

2  Foerster,  Archiv.  f.  Augenheilk.,  xii,3,  1881. 


IN'IRACAl'Sri.AR     l.\J  i;C  IK  )\  599 

introduction  of  a  ])lunt  instrument  throuj^h  the  corneal  incision  and 
gently  triturating  the  lens.  Jn  some  instances  this  procedure  was 
accompanied  by  iridectomy,  a  la  Foerster.  Although  this  operation 
had  many  advocates,  if  has  ever  had  many  harsh  critics,  among 
them  De  Wecker,  who  termed  it  the  "still-born  oi)eralion,"  and,  in- 
deed, it  seems  fraught  with  danger.  Except  in  the  hands  of  the 
most  skilled,  there  is  liability  of  damage  in  many  ways.  A  little  too 
much  pressure  on  the  spatula  during  massage  will  produce  luxation 
of  the  lens.  A  delicate  brittle  capsule  may  be  ruptured  and  followed 
by  rapid  swelling  of  the  lens  and  secondary  glaucoma.  Unavoidable 
injury  to  the  iris  may  produce  extensive  adhesions  or  even  irido- 
cyclitis. ISIoren  reports  one  case  followed  by  abscess  of  the  cornea 
and  another  by  iridocyclitis  and  insidious  phthisis  bulbi.  It  is 
generally  conceded  that  it  is  contraindicated  in  atheromatous  sub- 
jects, because  of  consecutive  glaucoma,  and  in  cataracts  accompanied 
by  choroidal  lesions.  After  some  ten  or  twelve  years  of  experiment- 
ing and  discussing,  the  cause  of  artificial  ripening  was  not  advanced. 
The  operation  was  about  as  formidable  as  the  subsequent  extraction, 
yet  the  perplexities  of  the  latter  were  in  no  way  lightened  by  it.  On 
the  contrary,  it  was  by  many  thought  to  increase  its  dilTiculties. 

III.  Intracapsular  Injection. — MacKeoun,^  basing  the  idea 
on  an  observation  of  Sir  \Vm.  Bowman  to  the  etifect  that,  when  the 
crystalline,  in  its  capsule,  was  put  in  a  vessel  of  water,  by  osmosis,  a 
separation  occurred  between  the  lens  substance  and  the  envelope, 
conceived  the  notion  of  maturing  cataracts  by  injecting  a  few  drops 
of  w^ater  by  means  of  a  Pravaz  syringe.  More  recently,  1899,  Jocqs, 
of  Paris,  proposed  the  same  measure,  only  substituting  for  the  water 
a  small  quantity  of  the  aqueous  humor  of  the  eye  concerned,  which  he 
injected  by  means  of  special  apparatus  devised  for  this  purpose. 
Whether  or  not  Jocqs  ever  tried  the  method  on  tlie  human  being, 
I  do  not  know.  He  believed  that  the  capsule  was  not  left  open, 
but  through  some  experiments  instituted  by  Mellinger,  of  Basle,  it 
has  been  demonstrated  that  cataracts  thus  produced  are  only  trau- 
matic ones  with  laceration  of  the  capsule.  Spataro  experimented 
on  the  eyes  of  23  rabbits  with  Jocqs'  method  and  produced  17  cases 
of  severe  iritis  and  2  cases  of  glaucoma.  He  also  proved,  by  control 
animals,  that  the  injection  of  aqueous  humor  was  much  more 
provocative  of  unpleasant  reaction  than  was  that  of  distilled  water 
or  of  normal  salt  solution. 

1  Ophth.  Society  of  Great  Britain  and  Ireland,  1885. 


6oO  EXTRACTION  OF  CATARACT 

IV.  Since  the  observation  of  Wallien,  in  1885,  to  the  effect  that 
exposure  of  the  eye  to  high  degrees  of  heat,  cataract  often  fol- 
lowed, a  number  of  similar  reports  have  occurred  in  ophthalmic 
literature.  Meyhofer,  for  example,  found  among  506  glass-blowers 
59  cataract  patients,  42  of  whom  were  under  40  years  of  age.  And 
out  of  30  workers  in  a  glass  factory,  Hirshberg  discovered  5  who, 
in  their  40th  year  had  cataracts.  Arlt  records  like  experiences. 
Hess  declared,  from  experiment,  that  high  degrees  of  heat  destroyed 
the  epithelium  lining  the  anterior  capsule,  and  thus  interfered  with 
the  nutrition  of  the  anterior  lens  fibres,  resulting  in  cataract.  With 
the  knowledge  of  these  facts.  Wolf  berg  (Die  Ophth.  Klinik,  No.  52, 
1904)  conceived  the  idea  of  opacifying  the  lens  by  means  of  a  hot-air 
douche.  For  the  purpose  he  invented  an  apparatus  which  he  calls 
a  "  Kalo-visator,"  by  which  a  stream  of  air,  heated  to  form  70  to 
100°  C,  is  passed  from  a  spirit  lamp,  through  an  asbestos  tube,  whose 
mouth  is  held  close  to  the  closed  lids.  He  estimated  that  the 
temperature  of  the  air  that  reaches  the  eye  varies  between  70  and 
80°  C.  The  applications  are  made  for  five  minutes,  two  or  three 
times  a  day,  for  eight  successive  days.  This  usually  insures  the 
desired  ripening.  He  uses  it  after  discission  in  high  myo])ia,  and 
after  iridectomy  in  senile  cataract. 

Bahr,  of  Mannheim,  at  the  Congress  of  Lucerne,  in  1904,  advo- 
cated the  making  of  a  paracentesis  in  immature  cataracts,  accom- 
panied by  direct  massage  of  the  lens  with  a  spoon  or  a  spatula,  as 
others  before  had  done,  but  with  the  difference  that  he  recommended 
a  somewhat  forcible  massage,  lasting  two  minutes,  and  that  the 
extraction  should  follow  after  only  five  days.  He  declared  that  not 
only  did  the  lens  shell  out  of  its  capsule  more  readily  after  this 
procedure  than  after  natural  maturation,  but  that,  owing  to  the 
new  vessels  at  the  site  of  the  incision  consequent  upon  the  first 
operation,  healing  was  more  prompt.  It  cannot  be  denied,  however, 
that  such  rubbing  of  the  lens  at  the  hands  of  any  but  the  most  skillful, 
would  often  lead  to  dislocation  and  loss  of  vitreous  and  other  com- 
plications in  the  extraction. 

Artificial  ripening  is  now  deemed  inexpedient  by  tlie  great 
majority  of  ophthalmic  surgeons,  e.xce])ting  in  a  very  small  pro- 
portion of  well-selected  cases.  When  it  is  resorted  to,  the  method 
usually  chosen  is  that  of  Foerstcr,  viz.,  iridectomy  and  massage 
through  the  cornea  with  tlie  back  of  a  Graefc  hard-rubber  s])Oon. 


HIS'IORICAI.  60  r 


HISTORICAL. 


Althouij;h  it  lias  Ix'cn  wiriously  liiiitfd  and  asscrlcd  thai  cala- 
ractous  lenses  were  removed  bodily  from  the  human  eye  hy  the 
ancient  surgeons  and  those  of  the  Middle  Aj^a-s,  yet  prior  to  the 
last  decade  of  the  lylh  century,  all  that  was  said  in  this  connection 
seems  to  have  rested  on  mere  assumption.  In  fact,  prexious  to  the 
period  just  alluded  to,  it  was  not  known  that  cataract  had  au<^ht 
to  do  with  the  crystalline,  but  was  thought  to  be  a  sort  of  ]jellicle  or 
film  situated  in  front  of  that  body.  The  discovery  that  cataract 
consisted  in  opacity  of  the  lens,  was  made  by  the  French  surgeon- 
oculist,  Antoine  j\Iaitrc-Jcan,  in  the  year  1691.  He  examined, 
postmortem,  the  eyes  of  a  woman  in  whose  case,  live  weeks  before 
her  death,  he  had  made  depression  in  both  eyes,  and  there  he  found 
the  opaque  lenses  lying  behind  the  lower  portions  of  the  irides. 
It  was  not,  however,  until  1705,  after  a  memorial  presented  to  the 
Paris  Academy  of  Sciences  by  the  younger  Brisseau,  that  the  truth 
as  to  their  identity  became  generally  known. 

It  is  recorded  that  Blancard,  of  Amsterdam,  had,  in  the  last 
decade  of  the  17th  century,  proposed  the  extraction  of  cataract, 
and  that  Johann  Conrad  Freytag,  of  Zurich,  had,  between  i6()2 
and  1698,  actually  undertaken  to  remove  portions  of  a  dislocated 
lens  from  the  anterior  chamber  through  a  corneal  incision. 

The  hrst  authentic  record  of  a  cataract  extraction  from  a  living 
subject  was  that  of  Charles  de  Saint-Yves,  surgeon  to  the  Hos])ital 
of  St.  Lazare,  at  Paris,  in  1707.  It  was  of  a  lens  that,  after  having 
been  depressed,  found  its  way  into  the  anterior  chamber,  and  the 
operation  was  undertaken  for  the  relief  of  pain,  the  eye  having  been 
sightless.  One  year  later,  St.  Yves  and  another  surgeon,  Francois 
Pourfour  du  Petit,  extracted  a  similarly  dislocated  lens  which,  two 
years  before,  had  been  couched.  This  last  case  not  only  served  to 
add  proof  to  the  idea  that  cataract  was  not  a  veil  in  front  of,  but 
cloudiness  within,  the  lens  itself,  but  also  to  demonstrate  the  true 
function  of  the  crystalline;  for,  with  the  aid  of  a  strong  convex  glass, 
the  patient  was  able  to  read  with  tlie  operated  eye.  The  presence 
of  the  lens  within  the  eye  had  always  been  considered  absolutely 
essential  to  sight. 

Mery,  who  assisted  in  the  operations  of  St.  Yves  and  Petit,  was 
the  first  to  conceive  and  propose  the  idea  of  extracting,  through  a 
corneal  incision,  a  cataract  from  behind  the  ])Upil. 


DESCRIPTION  OF  PLATE  IX. 

1.  De  la  Faye,  1752,  curved  on  the  flat. 

2.  Poyet,  1753. 

3.  Tenon,  1757. 

4.  Von  Graefe,  1855. 

5.  Daviel,  1750,  curved  on  the  flat. 

6.  DeWenzel,  1762. 

7.  Samuel  Sharp,  1753. 

8.  Warner,  1754. 

9.  Beranger,  1757. 

10.  Pamard,  1759. 

11.  Barth,  1795. 

12.  Beer,  1800. 

13.  Richter,  1770. 

14.  Young,  1756. 

15.  Jaeger,  1873,  right  and  left.  \ 

16.  Inouye,  1900.  1 

17.  Weber,  1867,  curved  transversely.  j 

18.  Taylor,  1900,  right  and  left.  j 


602 


I'LATK    IX. 


DAVIKI.  S    MKTIIOI)  605 

These  were  some  of  ihe  t"()rerunner>  of  ilic  operation  for  the  extrac- 
tion of  the  lens  from  its  normal  site,  as  first  | practiced, — also  by 
a  Frenchman,  the  immortal  Jean  Jac(iues  Da\iel —toward  the  end 
of  the  year  i  745.  Jt  was  while  makinj^  unsuccessful  efforts  lo  coucii 
a  cataract  that  it  occurred  to  him  to  oj:>cn  the  lower  ])ortion  of  the 
cornea  and  remove  the  obdurate  crystalline,  which  he  immediately 
proceeded  lo  do,  and  with  most  gratifying  results.  The  eye  recovered 
jjromptly  and  retained  good  vision.  Like  a  number  of  his  jiredeces- 
sors,  Daviel  had  already  extracted  fragments  of  cataracts  that  had 
wandered  into  the  anterior  chamber  after  depression,'  and  his 
experience  in  this  line,  added  to  the  success  of  the  extraction 
just  related,  incited  him  to  further  attempts  in  the  same  direction, 
and  from  that  time  he  began  the  systematic  extraction  of  cataracts. 
He  was  aware  of  the  shortcomings  of  the  older  operation  and  he 
pinned  his  faith  to  the  possibilities  of  the  new  one. 

In  1750,  he  was  called  to  Mannheim  to  operate  on  a  member  of 
the  royal  family,  and  while  there  made  three  extractions,  the  details 
of  which  he  narrated  in  a  letter  to  a  friend  in  Paris,  which  constitutes 
the  first  description  of  his  methods.  By  the  time  he  contributed 
his  notable  memoir  on  the  subject  to  the  Paris  Royal  Academy  of 
Surgerv  (Nov.,  1752),  he  hafl  made  20C)  extractions,  with  satisfactory 
results  in  182  instances. 

Daviel's  Manner  of  Operating  and  the  Instruments  he  Used. 
— Patient  and  operator  sat  in  chairs  facing  each  other.  He  began 
his  corneal  incision  near  the  lower  limbus  by  inserting  there  a 
small  lance-shaped  knife,  or  broad  two-edged  needle,  with  curved 
shank.  The  small  cut  thus  made  he  extended  in  either  direction 
by  means  of  a  similar  but  smaller  and  blunt-pointed  instrument.  If 
obliteration  of  the  anterior  chamber  and  Habbiness  of  the  cornea 
interfered  with  this  mode  of  extensicm,  he  substituted  small 
scissors.  Of  these  there  were  two  pairs,  one  curved  on  the  flat  and 
to  the  right,  with  the  right  blade  blunted,  and  the  other  curved  on  the 
flat  and  to  the  left,  with  the  left  blade  blunted— for  the  corresponding 
sides.  With  these  he  carried  the  incision  around  parallel  with  the 
limbus  in  each  direction  to  a  point  a  little  above  the  pupil,  which 
means  that  it  included  quite  a  little  more  than  one-half  of  the  cornea 
(Fig.  307).  He  afterward  limited  the  extent  to  one-half  the  circum- 
ference (see  cut).     He  lifted  this  large  flap   with  a  gold  or  silver 

1  David's  first  case  of  this  kind  was  in  tlie  year  i  745,  and  the  subject  was 
the  hermet  of  .\io;uille,  in  Province.     The  eye  was  lost  by  su]>i)uration. 


6o6 


EXTRACTION    OF    CATARACT 


Fig.  307.— Da 


spatula,  and  incised  the  anterior  capsule  with  a  small  curved,  two- 
edged  needle,  loosened  the  cataract  further,  if  need  be,  with  the 
spatula,  and  delivered  by  external  pressure  upon  the  lower  lid. 
Broken  masses  of  the  lens  were  laded  out  with  a  tiny  elongated  gold 
or  silver  scoop,  the  same  that  is  in  use  by  many  for  other  purposes 
and  by  a  few  for  the  same  to  this  day.  If  the  iris  got  into  the 
incision,  it  was  returned  to  the  anterior  chamber  by  manipulation  of 
the  spatula  and,  occasionally,  after  unusual 
wounding  of  the  iris,  the  injured  portion  was 
excised. 

It  will  be  seen  from  the  foregoing,  there- 
fore, that,  notwithstanding  the  lapse  of  160 
years,  the  best  efforts  of  all  of  his  successors 
and  the  many  modifications  and  changes 
that  have  been  suggested,  aside  from  the 
relatively  slight  variations  in  technic,  Daviel's 
operation  was  not  essentially  different  from 
the  most  approved  at  the  present  time. 

Let  us  note  some  of  the  phases  through  which  the  corneal  section 
has  passed  and  some  of  the  forms  and  alterations  that  have  charac- 
terized the  cataract  knife. 

Changes  in  the  Incision. — When  one  contemplates  how  impor- 
tant is  the  role  played  by  the  primary  section  or  opening  of  the  globe, 
its  position,  form,  and  extent,  in  the  operation  of  extraction,  it  is 
truly  remarkable  how  near  it  still  is  in  these  respects  to  Daviel's 
conception.  True,  he  made  the  corneal  flap  downward  (excepting 
that  for  a  short  time,  while  in  his  last  days,  he  experimented  with  a 
new  triangular,  or  ogival  flap,  which  he  tried  outward  and  also  upward 
as  well  as  downward)  as  did  all  of  his  successors,  with  but  few 
exceptions,  for  more  than  a  century.  In  1784,  Pierre  Pamard, 
of  Avignon,  made  an  upward  section.  This  surgeon  had  adopted 
Daviel's  operation  as  early  as  1758,  and  had  striven  earnestly  to 
improve  it.  He  broke  away  from  tradition  sufficiently  to  operate 
his  patient  lying.  He  used  a  lance-shaped  knife  of  his  own  invention, 
as  also  a  sharp  hook  with  which  to  steady  the  eyeball.  The  elder 
Baron  de  Wcnzel,  in  1766,  using  his  broad  double-edge  knife,  made 
an  u])ward  and  outward  flap,  and  his  son,  Michel  Jean  Baptiste  de 
Wenzel,  about  1800,  was  one  of  the  pioneers  of  the  upward  method. 
In  Germany,  among  the  first  enthusiastic  advocates  and  modifiers 
of   Daviels's   operation,    was    August    (lotllob    Richter,    tlie   justly 


HISTORY    OF    TIIK    INCISION 


607 


celebrated  surgeon  of  Gotlingen,  whose  labors  exlcnded  over  some 
twenty  years,  or  from  about  1770  to  1790.  He,  too,  made  downward 
section,  including  one-half  the  cornea,  with  a  knife  like  that  of 
Beranger,  of  Bordeau,  save  that  for  a  short  distance  it  was  doul)k'- 
edged  (Fig.  308). 

The  work  of  Richter  was  carried  on  by  liarlh.  of  X'icnna.  and  by 
his  successor,  the  great  Beer,  the  teacher  of  Oracfe.  Langenbeck, 
and  the  elder  Jaeger,  To  the  latter  he  became  also  father-in-law. 
Barth  is  said  to  have  devised,  in  1705,  the  triangular  cataract  knife 
commonlv   accredited    to    Beer.     Barth   changed    the   edge   of   the 


Fig.  30S.— Richter,  17S0.      Fig.  309.— Barth  &  Beer,  1795 


Beranger  knife  from  convex  to  straight,  claiming  for  the  latter  forni 
better  cutting  qualities  and,  like  Daviel  and  Richter,  made  a  down- 
ward flap,  including  half  the  corneal  base  (Fig.  309).  It  may  be 
mentioned  that  almost  all  of  the  operators,  from  Daviel  down  to  the 
time  of  Beer— yes,  even  to  the  time  of  Desmarres— extracted  with- 
out the  use  of  either  lid  speculum  or  fixation  appliance,  which  fact 
speaks  well  for  their  prudence  as  well  as  for  their  dexterity.  Richter 
and  Beer,  operating,  respectively,  in  (k-rmany  and  Austria,  so  im- 
proved the  instruments— in  short,  so  advanced  the  status  of  the 
operation— that  their  methods  have  been  termed  classic;  and,  as  a 
further  tribute,  their  additions  to  the  measure  were  adopted  in  the 
home  of  Daviel  by  the  two  greatest  living  ophthalmic  surgeons,  Sichel 
and  Desmarres.  (For  other  reference  to  Riclitcr  and  Beer,  see  sec- 
tion on  Extraction  of  the  Lens  in  its  Cai)sule.) 

Another  school  of  surgeons,  beginning  with  Palucci,  in  1752 
(Fig.  310),  and  later,  Santerelli,  in  1795,  sought  to  renew  the  linear 
extraction,  though  their  efforts  were  not  strongly  seconded  (Fig.  311). 
This  was  the  form  as  instituted  bv  Saint-Vves  and  Petit,  the  fathers 


6o8 


EXTRACTION    OF    CATARACT 


of  extraclion,  and,  as  if  lo  mark  ihe  centenary  of  their  discovery, 
a  revival  of  linear  extraction  was  inaugurated  by  Gibson,  of  Lon- 
don, in  i8i  I,  and  by  Friederick  Jaeger,  of  Vienna,  in  1812.  Indeed, 
it  was  the  latter  who  gave  the  o])eration  the  designation,  linear. 

This  movement  had  its  culmination  in  Great  Britain,  having 
been  given  great  impetus  by  Travers  (1814)  and  Burton,  of  London 
(about  1820).  The  former  was  especially  instrumental  in  forward- 
ing it,  and  the  fruits  of  his  activity  are  visible  in  the  latest  phase  of 
the  operation.  He  strove  for  a  minimum  incision,  and  for  a 
method  free  from  loss  of  vitreous  and  iris  complications,  also  for  one 
less  difHicult  in  the  making,  seeing  that  with  such  an  incision, 
blepharostat  and  fixation  forceps  could  be  used  with  more  confi- 
dence.    He  first  limited  his  form  of  extraction  to  soft  cataracts. 


Fig.  310. — Pelluci,  175 


Santerelli,  1795. 


With  a  reclination  needle,  he  dislocated  the  lens  into  the  anterior 
chamber,  then  extracted  it  through  a  small  linear  corneal  incision, 
Traver's  wound  was  made  above  and  included  just  1/4  of  the  corneal 
margin,  hence  it  became  known  as  Traver's  Quarter  Section  (Fig.  312). 
Later  he  applied  this  kind  to  extraction  in  general,  not'limiting  it  to 
certain  soft  cataracts,  and  those  that  had  been  previously  broken  up 
as  by  discission,  using  a  sort  of  thin  spoon  to  deliver  the  lens.  In 
after  years  Sir  William  Bowman  and  the  elder  Critchett,  of  London 
(1864),  reverted  to  the  Travers'  operation,  though  they  extended, 
with  scissors,  the  incision  begun  with  the  keratome,  so  as  to  in- 
clude 1/3  or  more  of  the  corneal  base,  added  an  iridectomy,  and 
employed  a  thin,  broad,  curved  s])oon  or  spatula  as  the  traction 
instrument  {scoop  extraction). 

In  the  meantime,  Albrecht  v.  Graefe,  of  Berlin,  had  begun  his 
brilliant  though  brief  career.     After  Daviel,  he  who  made  the  most 


HISTORY    OF    THE    INCISION' 


609 


profound  impression  upon  the  ])rinciples  and  the  art  not  only  of  the 
surgery  of  cataract,  but  upon  the  science  of  ophthalmology  as  a 
whole,  was  von  Graefe.  At  the  early  age  of  thirty  he  had  sounded 
the  depths  and  the  shallows  of  the  two  methods  of  linear  and  flap 
extraction.  He  recognized  their  respective  failings  and  advantages. 
From  the  suppurations  and  lack  of  coaptation  of  the  flap  extraction, 
he  sought  refuge  (1853)  i^  the  more  prompt  healing  of  the  linear 
incision  placed  in  the  sclera;  and  from  the  iris,  capsule,  and  cortex 


Fig 


Fig.  313. — Von  Graefe,  1S59. 


complications,  in  the  removal  of  the  contiguous  portion  of  the  iris, 
as  first  definitely  recommended,  as  a  part  of  the  operation,  by 
Schifferli,  of  Jena,  in  1776.  In  this  he  reverted  to  the  operation  of 
Travers,  making  a  small  incision  in  the  upper  limbus,  adding  iri- 
dectomy, and  delivering  the  lens  by  means  of  the  clumsy  spoons 
devised  by  his  assistant,  Waldau.  He  confined  the  operation  to 
the  softer  forms  of  cataract  or  to  those  with  soft  cortex  and  small 
hard  nucleus.  But  for  the  sclerosed,  more  voluminous  senile 
cataracts  he  still  made  the  flap  extraction.  Little  by  little  he 
raised  and  extended  the  incision  of  Travers,  until  it  approached 
more  nearly  to  the  linear,  in  effect,  until  it  was  finally  placed 
wholly  in  scleral  tissue,  substituting  for  the  lance-knife  his  straight 
narrow  Schmalmesser  (1859).     (Fig.  313.) 

Although  Daviel  never  relinquished  his  early  manner  of  making 
the  section,  i.e.,  beginning  with  his  small  lance-knife  and  enlarging 
with  knife  and  scissors,  his  friend  and  colleague,  George  de  la  Faye, 
as  early  as  1752,  suggested  a  narrow  bistoury,  curved  on  the  flat,  for 
making  the  entire  flap  at  one  cut  (Plate  IX,  No.  i).  This  one- 
instrument  idea  was  put  into  execution,  about  a  year  later,  by  Samuel 
39 


6lO  EXTRACTION  OF  CATARACT 

Sharp,  of  London,  though  with  a  triangular  knife  of  his  own  design 
(Plate  IX,  No.  7).  There  were  thus,  in  the  very  beginning,  the 
three  leading  models  of  the  corneal  knife,  viz.,  Daviel's,  De  la  Faye's, 
and  Sharp's.  These  are  the  precursors,  of  which  all  that  have 
since  been  devised  are  but  modifications. 

Daviel's  (Plate  IX,  No.  5)  was  the  parent  of  the  trowel  form  (de 
Wenzel's,  Weber's,  etc.)  of  which  the  modern  representative  is  the 
lance-keratome.  Sharp's  found  its  counterparts  in  the  various 
half-dart  forms  (Beranger's,  Pamard's,  Himly's,  and  Jaeger's) 
whose  latest  survivor  is  the  Beer's  knife;  while  De  la  Faye's  was 
the  progenitor  of  the  narrow,  straight  type  now  in  general  use, 
coming  down  through  that  of  Poyet,  Tenon,  and  v.  Graefe. 

It  must  be  remembered  that  the  true  Graefe  Schmalmesser  was  of 
decidedly  different  pattern  from  that  which  still  bears  the  name,  and 
is  the  almost  universally  accepted  form.  A  glance  at  Plate  IX.  No.  4 
will  at  once  make  the  difference  apparent.  The  original  Graefe  blade 
was  longer  and  broader,  the  edge  and  back  w^ere  perfectly  parallel 
up  to  within  some  three  or  four  millimeters  of  the  end,  whence  the 
blade  was  two-edged  to  the  point,  i.e.,  the  tapering  portion  was 
two-edged. 

It  is  now  more  than  fifty  years  since  v.  Graefe  devised  his  so-called 
modified  linear  incision,  though,  to  speak  technically,  it  was  not 
what  its  name  implies,  but  a  high  or  scleral  and  conjunctival  flap 
of  low  arc.  It  began  on  either  side,  one  and  one-half  to  two  milli- 
meters behind  the  sclero-corneal  junction,  and  was  carried  upward 
and  forward,  with  a  slight  curve,  and  ended  with  a  small  con- 
junctival flap,  barely  posterior  to  the  junction.  In  conjunction  he 
made  a  very  broad  and  very  peripheral  iridectomy.  Graefe  suc- 
ceeded thus  in  making  a  perfectly  coapting  and  quickly  healing 
incision  which  greatly  reduced  the  frequency  of  infection,  but 
at  the  expense  of  other  disasters  which  more  than  otTset  its 
advantages. 

Among  these,  on  account  of  the  proximity  of  the  cut  to  the  zonule 
and  the  ciliary  body,  were  a  large  proportion  of  vitreous  losses 
(about  one  in  seven),  and  because  of  the  tremendously  peripheric 
iridectomy — deep  uveitis,  with  punctate  keratitis,  and  almost 
constantly  recurring  entanglements  of  the  iris  and  shreds  of  capsule 
in  the  angles  of  the  incision,  leading  to  drawing  upward  of  the  iris, 
to  dense  secondary  cataract,  and  to  closure  of  the  pupil.  Moreover, 
it  was  but  natural  that  in  addition,  and  as  sequels  to  these  mishaps. 


HISTORY    OF    THE    INCISION  6ll 

the  Still  greater  terrors,  glaucoma  and    symi)athetic    ()i)luhalmia, 
became  more  obtrusive. 

De  Weckeri  says:  "Personne  nc  j)ourra  nier  (jue  les  oijlitiialmies 
sympathiques,  presque  inconnucs  au  temps  dc  Daviel,  Wenzel,  Hcer, 
Sichel  et  Desmarres,  n'aient  fait  leur  trisle  apijuriiion  epic  depuis, 
d'apres  Jacobson  et  de  Graefe,  on  a  pousse 
davantage  la  section  vers  la  region  sclero- 
ticale,  et  qu'on  s'est  rapproche  plus  en  plus 
de  Tangle  iridien,  mis  en  outre  a  deconvert 
par  I'excision  de  I'iris,  generalisee  comme 
methode  operatoire." 

For  tiiese  reasons  this  master  was  soon 
constrained  to  alter  his  course.  As  Panas- 
expresses  it,  "De  Graefe  with  his  well- 
known  sincerity  in  matters  scientific,  was 
the  first  to  indicate  the  weak  points  of  his  method."  Consequently 
he  brought  his  incision  further  forward,  approaching  more  nearly 
the  small  corneal  flap,  and  reduced  the  size  of  his  iridectomy 
(Fig.  314).  Having  heard  much  of  the  brilliant  results  achieved 
by  Bowman  and  Critchett,  with  their  scoop  extraction,  and,  to 
again  quote  Panas,  "  Desirous  of  observing  their  work,  in  the  fall 
of  1864,  he  made  a  trip  to  London,  and  on  his  return  to  Berlin, 
he  made  118  extractions  after  the  English  mode.  Among  the  num- 
ber, he  had  11  total  failures  by  panophthalmitis  or  consecutive 
cyclitis,  28  occlusions  of  the  pupil,  that  necessitated  ultimate 
intervention,  and  11  abundant  losses  of  vitreous;  not  to  mention 
the  fact  that,  in  many  cases,  the  ejection  of  the  lens  remains  was, 
laborious  and  often  incomplete." 

So,  with  indomitable  perseverance,  he  strove,  till,  by  his  modified' 
flap  operation  and  the  accession  of  the  compressive  bandage — 
about  1864 — he  was  at  last  able  to  announce  that  in  900  consecutive 
extractions  he  had  a  loss  by  panophthalmitis  of  but  5%.  About 
this  time,  Graefe's  colleague,  Jacobson,  came  to  the  front  with  his 
conception  of  the  flap  extraction.  This  consisted  in  a  downward 
section,  situated  one-half  millimeter  behind  the  conjunctival  limbus 
or  in  the  opaque  cornea,  and  included  just  one-half  of  the  corneal, 
base  (Fig.  315),  and  was  combined  with  an  enormous  iridectomy. 
Through  the  efforts  of  these  two  surgeons,  ere  the  dawn  of  antisepsis,. 

1  Trait e  conplet  d'  Opht.  de  Weckerand  Landolt,  vol.  ii,  p.  1016. 
-Panas,  Maladies  des  Yeux,  vol.  i,  p.  576. 


6l2 


EXTRACTION  OP  CATARACT 


the    occurrence    of    suppuration,    after    cataract    extraction,    was 
reduced  to  at  least  one-half  what  it  had  formerly  been, 

Following  close  upon  Graefe,  Jacobson,  Bowman,  and  Critchett 
came  De  Wecker,  of  Paris,  about  1869,  offering  his  combined  oper- 
ation. Its  feature  was  an  upward  corneal  flap,  two  to  three  milli- 
meters high,  made  by  an  incision  beginning  in  the  sclera,  on  either 
side,  and  ending  in  the  limbus,  thus  having  scleral  ends — "Extrac- 
tion comblnee  a  petit  lambeau."  The  length  of  De  Wecker's  incision 
was- II  millimeters,  whereas  v.  Graefe's  linear  was  10  millimeters 
(see  Fig.  316).     This  he  afterward  (1875)  altered  to  his  two  milh- 


FiG.  315. 
Jacobson,  1864. 


Fig.  316. 
De  Wecker,  1869. 


Fig.  317. 
De  Wecker,  1875. 


meters  high,  purely  corneal  flap,  exactly  in  the  upper  limbus,  and 
including  just  1/3  of  the  corneal  circumference  "  detachment  of  the 
superior  third  of  the  cornea" — and,  most  important,  returning  to  the 
method  of  Daviel  in  that  he  omitted  the  iridectomy — "Extraction 
simple  a  petit  lambeau"  (Fig.  317). 

For  the  fashioning  of  his  section  De  Wecker  used  a  knife  modeled 
after  that  of  v.  Graefe,  though  hardly  more  than  half  the  width,  and 
gradually  increasing  in  thickness,  at  the  back,  from  point  to  heel, 
until  at  the  shank  it  was  one  millimeter  through.  Something  the 
shape  of  a  three-cornered  steel  file.  While  this  particular  pattern 
has  not  been  perpetuated,  it  undoubtedly  was  •  he  forerunner  of  the 
changes  that  have  culminated  in  the  type  in  general  use  at  the 
present  momnet.  (For  description  of  said  type,  see  chapter  on  the 
Management  of  Instruments.) 

Thus,  after  wandering  up  and  down  the  world  for  more  than  a 
century  and  a  quarter,  undergoing  many  vicissitudes,  alternately 


HISTORY    OF    THE    IN'CISION 


613 


nourished,  starved,  and  forsaken,  do  ^ve  sec  the  oj)eration  of  extrac- 
tion enter  into  its  rightful  heritage  in  ihe  Lind  oi  its  birth.  For  it 
was  the  notable  contribution  of  De  Wcckcr'  in  1S75,  to  the  Paris 
Academy  of  Sciences,  that  sounded  the 
knell  of  abaissement  and  reclination,  and 
antisepsis  gave  the  coup  de  grace.  rre\Mous 
to  this  there  had  never  been  a  time  when 
the  latter  procedures  were  not  extensively 
practised  and  that,  too,  by  the  shining  lights 
of  ophthalmology.  Over  and  over  again 
would  they  drop  extraction  to  take  up  the 
primitive  method. 

To  conclude  this  history,  already  too 
lengthy,  here  follows  brief  mention  of  a  few  other  modes  of  making 
the  keratotomy  that  were  devised  in  the  scant  years  prior  to  De 
Wecker's  paper. 

About  the  year  1867,  Adolph  Weber,-  of  Darmstadt,  had  con- 
structed, for  making  the  linear  incision,  a  broad  lance-knife,  some- 
thing after  the  model  of  the  old  Santerelli  knife  of  1795.  It  dilTered 
from  the  modern  wide  iridectomv  knife  onlv  in  having  a  blade  concavo- 


FiG.  31S.— Wcbc 


Fig.  319. 
Kiichler,  i86S 


Fig.  320. 

Liebreich,   1872. 


Fig. 32] 
Ed.  Jaeger, 


convex,  in  the  transverse  sense,  with  the  convexity  directed  upward 
(Plate  IX,  No.  17).     It  was  designed  to  make  an  incision  similar 
to   Graefe's  modified  linear,    only  less  peripheral    and  doii'incard 
(Fig.  318).     It  was  probably  deserving  of  a  longer  life. 
Kuchler's  Incision. ^ — About  the  same  time  that  Weber  invented 


^  Wecker,  Comptes  Rendus  de  I'Acadamie  des  Sciences,  T.  Ixxx,  p.  i2()4. 

2  Arch.  f.  Ophthal.,  xiii,  p.  187. 

3  Kiichler.  Ueber  die  Querextraktion  des  Staars  Memorabilien,  xii, 
I,  1867,  and  die  Querextraktion  des  grauen  Staars  der  Erwachsenen,  Erlan- 
gen,  V.  8,  p.  37,  1868. 


6 14  EXTRACTION    OF    CATARACT 

his  knife,  his  colleague  and  fellow  townsman,  Kiichler,  conceived 
the  idea  of  applying  to  extraction  an  incision  he  had,  in  1853, 
designed  and  employed  in  operating  for  anterior  staphyloma.  It 
was  nothing  more  nor  less  than  an  actual  transverse  section  of  the 
cornea,  lying  exactly  in  the  horizontal  meridian,  and  extending  from 
base  to  base  (Fig.  319).  And,  by  the  way,  this  was  the  only  true 
linear  cut  that  was  ever  made  for  such  a  purpose.  Kiichler  called 
it  Querextraktion.  Although  a  very  poor  surgical  measure,  its  name 
serves  to  perpetrate  a  passable  English  pun. 

Liebreich's^  Incision. — This  was  a  modification  of  the  v. 
Graefe  linear  incision,  made  downward,  and  with  the  narrow  knife 
(Fig.  320).  Puncture  and  counterpuncture  were  made  about  two 
millimeters  below  the  horizontal  meridian  and  one  millimeter  back  of 
the  corneal  base.  The  edge  was  directed  downward  and  forward, 
cutting  in  a  gentle  curve,  and  coming  out  two  or  three  millimeters 
above  the  lower  limbus.     The  iridectomy  was  omitted. 

Jaeger's-  Incision.— Edward  Jaeger,  of  Vienna,  with  the  idea  of 
accomplishing  the  Graefe  peripheral  linear  incision  by  a  single  for- 
ward cutting  movement,  as  his  grandfather.  Beer,  made  the  Daviel 
large  flap,  constructed  a  pair  of  knives,  or  as  he  called  them,  Hohl- 
messers,  one  for  the  right  eye  and  the  other  for  the  left  (Plate  IX, 
No.  15).  If  flattened  out,  their  blades  would  have  been  like  the 
Beer  knife  only  longer  and  narrower.  Instead  of  being  flat,  however, 
they  were  concavo-convex  in  their  sagittal  planes;  and,  in  order  to 
conform  to  the  curve  of  the  Graefe  incision,  they  were  introduced 
with  the  concavity  forward  (see  Fig.  321).  They  proved  to  be 
more  ingenious  than  practicable.  His  incision  was  similar  to  v. 
Graefe's,  but  longer  by  three  millimeters. 

Lebrun's^  Incision. — Under  the  name,  "Extraction  with  a 
small  median  flap,"  Lebrun,  of  Brussells,  contrived  a  purely  corneal 
incision.  With  a  medium-sized  Graefe  knife,  edge  directed  upward 
and  slightly  forward,  he  made  puncture  and  counterpuncture  slightly 
below  the  horizontal  meridian,  exactly  in  the  limbus.  The  cut 
extended  up,  with  a  light  forward  curve,  and  ended  at  the  junction 
of  the  upper  with  the  middle  third  of  the  vertical  meridian  of  the 

1  Liebreich.  Eine  neue  Methode  der  Cataract  Operation,  Berlin,  1872. 
Also  Saint  Thomas  Hospital  Reports,  vol.  ii,  p.  259. 

2  Der  Hohlschnitt.      Vienna  V.  80,  p.  23,  1873. 

3  Lebrun.  Methode  de'extraction  de  la  cataracte  par  un  procede  a 
lainbeau  median  spiro-cylindrique.  Trans.  London  Internat.  Congress, 
p.  2i().  1873. 


THE    MODERN    INCISION 


615 


cornea,  or  about  on  a  level  with  the  upper  bonier  of  the  averaj^e 
pupil  (Fig.  322).  Warlomont  called  this  the  Hvli^ian  Method.  De 
VVecker  added  that,  in  point  of  prudence,  it  mi,^dit  belter  be  termed 
the  neuter  method. 

The  graver  faults  of  these  sections,  lying  well  within  tiie  trans- 
parent cornea,  are  want  of  coaptation,  contact  with  the  jJUjjiUary 
border  of  the  iris  while  the  anterior  chamber  is  empty,  causing  the 
iris  to  become  entangled,  slow  healing,  from  being  far  from  the 
blood  supply  (liability  to  infection),  and  high  degrees  of  astigmatism 
in  cicatrization.     One  of  tlie  \ery  complications  that  it  was  the  aim 


Fig.  322. — Lebrun 


Fig.  324. — Horner,  1884. 
In  scleral  tissue. 


of  such  sections  to  obviate  was,  if  anything,  yet  more  frequent,  viz., 
picking  up  of  the  iris  by  the  incision.  This  fact  helped  to  disprove 
the  old  rule  that  the  nearer  the  incision  to  the  sclera,  the  more  urgent 
an  iridectomy. 


THE  MODERN  CORNEAL  INCISION. 

"L'operation  de  la  cataracte,  c'est  la  section." — Terrien. 
In  view  of  the  foregoing  considerations,  relative  to  the  various 
forms  of  the  primary  incision  for  the  extraction  of  cataract,  it  would 
seem  a  fitting  close  to  the  subject  to  define  just  what  constitutes  a 
proper  section;  for  it  is  on  this  that,  in  great  measure,  we  rely  for 
success  in  the  operation.  What  is  its  particular  configuration, 
extent,  and  position  as  most  approved  at  the  present  time  ?  We  have 
noted  some  of  the  faults  of  the  highly  peripheral  or  scleral  sections 
(p.  610)  and  of  those  that  lie  far  in  the  opposite  direction  (p.  615). 
It  may  be  stated,  then,  that  an  intermediate  position  is  desirable; 
and  the  one  chosen  is  precisely  at  the  junction  of  the  cornea  and  the 


6i6 


EXTRACTION    OF    CATARACT 


conjunctiva,  the  direction  of  the  flap  being  upward — superior  kera- 
totomy — and  ending  with  or  without  a  conjunctival  flap;  the  whole 
section  lying  in  a  plane  parallel  with  that  of  the  base  of  the  cornea 

(Fig-  325)- 

As  regards  the  proper  extent  of  the  incision,  or,  in  other  words, 
its  length  as  measured  around  the  corneal  base,  there  have  been  no 
definite  limits  fixed,  nor  is  it  practicable  to  do  so,  except  approxi- 
mately. There  must  be  some  latitude  in  the  matter.  We  have 
seen  how  very  objectionable  is  a  wound  too  small,  yet,  how  seem- 
ingly little  it  matters  if  it  be  larger  than  necessary.  Therefore, 
knowing  the  uncertainties  of  the  act,  one  may  so  begin  his  section 
as  to  favor  the  chances  of  erring  on  the  safe  side,  i.e.,  of  needless 

length.  The  supposed  size 
of  the  cataract,  for  example, 
or  the  particular  difficulties 
that  are  apprehended  in  a 
given  case,  of  necessity,  in- 
fluence the  operator's  judg- 
ment in  selecting  the  points  of 
puncture  and  counterpunc- 
ture.  Manifestly,  these  two 
points  mark  the  lower  bounds 
of  the  incision,  and  are  sup- 
posed to  be  on  the  same  hori- 
zontal level.  Assuming  that 
these  terminals  can  be  accu- 
rately placed  as  desired — ■ 
which  at  the  hands  of  the  ex- 
perienced operator  is  pretty 
certain — and  that  the  cut  will 
unerringly  follow  the  limbus  from  start  to  finish,  one  might  with 
tolerable  certainty  give  a  uniform  configuration,  position,  and  extent. 
Now,  such  infallibility  is  not  possible  to  the  skillful,  even  in  operat- 
ing on  pig's  eyes  in  a  mask,  much  less  so,  to  all  degrees  of  dex- 
terity, in  dealing  with  the  living  human  eye,  in  subjects  possessed 
of  all  grades  of  sense  and  sensitiveness. 

Hence,  the  making  of  a  uniformly  satisfactory  corneal  section 
is,  perhaps,  the  most  difficult  feat  in  all  surgery — a  feat  to  which 
the  greatest  has  never  attained.  Agnew,  with  all  the  marvelous 
precision  of  his  art,  and  De  Wecker,  startlingly  brilliant  as  he  was, 


325. — Modern  incision  for  cataract. 


THE    MODERN    INCISION 


617 


I  have  seen  baffled  in  their  aim  in  this  parlicuhir.  True,  if  one 
were  satisfied  to  habitually  make  an  unduly  larL,'c  section,  the  thing 
might  be  easier. 

In  order  to  locate  the  site  of  puncture  and  counterinmcture,  it 
has  been  customary,  with  most  operators,  to  select  a  certain  fraction 


P'IG.  326. 

a  a.  Vertical  diameter.     The  divisions  represent  millimeters. 

hh.  One-fourth  the  circumference  or  a  little  over  one-seventh  the  diameter. 

cc.  One-third  the  circumference  or  one-fourth  the  diameter. 

dd.  One-third  the  diameter  \  ^^    ^  f^„  approximately  together. 

e  e.  Two-hfths  the  circumference  J  t-i  j      •= 

ff.  Two-fifths  the  diameter. 

gg.  One-half  the  diameter  also  one-half  the  circumference. 

of  the  corneal  circumference  that  shall  be  detached:  Daviel,  1/2  to 
10/16;  Travers,  1/4;  Critchettand  IJe  Wecker,  1/3;  Panas,  2/5,  etc., 
the  idea  being  to  bisect  the  extremities  of  this  chosen  arc  as  puncture 
and  counterpuncture.  To  me,  a  readier  way  has  always  seemed 
the  fancying  of  a  sort  of  scale  marked  ujion  the  vertical  diameter  of 
of  the  corneal  base,  and   to   choose  ihercon   the  level   of  ihe  two 


6i8 


EXTRACTION    OF    CATARACT 


points.  In  other  words,  to  place  the  horizontal  chord  of  the  arc 
and  not  the  arc  itself.  It  will  be  seen  by  looking  at  Fig.  326,  that 
Travers'  quarter  section  arc  included  about  1/6  of  said  diameter; 
Critchett's  and  De  Wecker's  1/3  arc  just  1/4  the  diameter,  and 
Stellway  v.  Carion's  and  Panas'  2/5  arc  about  1/3  of  the  diameter. 
Now,  Travers'  section  is  obviously  too  small  for  other  than  in- 
strumental delivery  of  any  ordinary  cataract,  although  it  were  made 


Fig.  327. — 0  0.   Optic  axis.     BB.  Plane  of  corneal  b 
PP.  Positive  inclination.     A^A^,  Negative  inclination. 


II. 


LL.  Linear  incision. 
Iridectomy  incision. 


in  the  plane  of  the  greatest  corneal  curve,  viz.,  the  base,  and  with  the 
curve  of  both  wound  openings  parallel,  which,  of  course,  would 
mean  as  near  as  possible  to  the  true  linear  section  (Fig.  327). 
Critchett's  and  Ue  Wecker's,  if  it  could  be  made  ideal,  i.e.,  exactly  in 
the  base  and  with  the  minimum  of  difference  in  the  size  of  outer  and 
inner  wound  openings,  should  be  adequate  for  any  ordinary  senile 
cataract.  Several  things  may  conspire,  however,  to  make  this  im- 
possible, as  a  shallow  anterior  chamber,  an  intractable  patient,  early 
escape  of  the  aqueous,  etc.     It  may  be  set  down,  therefore,  that  a  Hap 


THE    MODERN    INCISION 


6lQ 


whose  height  (or  breadth)  is  equal  to  one-third  of  the  ch'ameter  of  the 
corneal  base — or  about  equivalent  to  two-fifths  of  the  circumference, 
as  recommended  by  Stellwag  and  Panas — if  made  with  due  regard 
to  the  rule  of  the  procedure,  will  afford  an  ample  opening  for  the 


Fig.  328. — Ideal  section. 

largest  lens,  and  leave  margin  enough  to  cover  slight  irregularities. 

What  are  the  rules  or  principles  to  be  observed  in  the  fashioning 

of  the  flap  or  of  the  incision?  Aside  from  those  already  mentioned 


Fig.  32Q. — Split  in  counterpuncture  i)unc 


as  to  position  and  extent,  the  most  im])orlant  has  reference  to  the 
configuration,  and  may  be  thus  concisely  stated:  Let  there  be  the 
leas  possible  difference  between  the  sizes  of  the  inner  and  outer  wound 
openings  (the  minimum  length  of  "wound-canal,"  as   the  Germans 


620 


EXTRACTION  OF  CATARACT 


call  it) .  How  to  accomplish  this  result  ?  The  briefest  answer  to  this 
question  is,  avoid  splitting  the  cornea.  Make  the  breadth  of  the  lip 
of  the  incision  at  a  given  point  approximate  the  thickness  of  that 
portion  of  the  cornea  (Fig.  328).     This  is  best  effected,  first,  by 


Fig.  330. — Split  in  finishing. 

holding  the  blade  of  the  knife  perpendicular  (or  nearly  so)  to  the 
tangent  of  the  corneal  curve  in  making  the  puncture,  then  depress- 
ing the  handle  (in  the  backward   sense,  or   toward   the   patient's 


Fig.  331. — Counlrr-puiK  lure  too  far  forward. 

temple),  all  the  while  ])usliing  the  point  of  the  blade  to  a  point 
opposite  the  center  of  the  pupil,  and  again  (lc|)rcssing  the  handle 
(this  time  in  the  downward  sense,  or  toward  Ihe  patient's  feet)  to 
make   the   counlerpunclurc.     This  gives   the    most    direct  wound 


THE    MODKRX    INCISION'  62 1 

angle,   in  both  vertical   and   hori/onta!  i)lanes,  lliat  it  is  jjossiblc  to 
make. 

The  wound-lips  at  the  counterpuncture  can  never  be  so  sleep  as 
at  the  puncture  (Fig.  329),  because  they  must  be  made  with  the 
blade  in  the  horizontal  position.  The  object  here,  then,  is  to  keep 
the  knife  down  close  to  the  iris  so  as  to  go  most  directly  through  the 
cornea.  The  further  back  the  counterpuncture  the  larger  the 
opening,  or  at  least,  the  more  nearly  in  the  limbus;  but  the  de- 
ceptive refraction  which  makes  the  knife  appear  much  nearer  than 
it  really  is  must  be  borne  in  mind  (see  descri])ti()n  of  operation  on 


Fig.  332. — Split  at  all  points.- 

p.  523),  In  this  way,  although  the  inner  angle  of  the  incision  is 
less  direct  than  the  outer,  not  only  is  an  ample  opening  insured, 
but  there  is  less  risk  of  making  the  lips  too  slanting  in  the  rest  of 
the  section  (see  Fig.  332). 

By  the  time  the  two  punctures  are  made,  cutting  upward 
is  already  under  way,  as  it  were,  the  knife  is  held  strictly  to  the 
limbus,  on  both  sides,  and,  as  the  edge  disappears  in  the  upper 
iridic  angle,  if  a  conjunctival  flap  is  desired,  it  (the  edge)  is  turned 
backward  to  emerge  beneath  the  membrane. 

I  look  upon  this  flap,  identified  with  Desmarres,  as  one  of  the 
keys  to  the  situation,  not  alone  in  simple  extraction,  but  in  the 
combined  as  well.  It  is  not  prone  to  become  misplaced,  but  clings 
to  its  original  site  with  singular  pertinacity,  and  heals  solidly  in 
a  few  hours,  thus  holding  the  incision  closed;  and  to  be  held  shut 
favors  primary  union,  absence  of  iris  com]:)lications,  and  many  other 


62  2  EXTRACTION    OF    CATARACT 

untoward  happenings.  It  need  not  be  in  the  way  of  the  subsequent 
operations,  such  as  delivery  of  the  cataract  and  cortex  and  the 
toilet  of  the  eye,  as  it  is  easy  enough  to  turn  it  over  onto  the  cornea. 
As  for  any  hemorrhage,  that  may  be  occasioned  by  it,  that  is  not 
to  be  considered  at  all.  Just  before  final  closure  of  the  eye  it 
must  be  seen  to  that  the  flap  is  nicely  coapted — not  caught  in  the 
cut,  etc. 

Could  one  determine  with  anything  like  certainty  before  operating 
the  dimensions  and  consistency  of  the  cataract,  the  size  of  the  flap 
or  of  the  section  might  be  planned  to  suit  the  individual  case. 
Since  this  is  not  feasible,  it  is  better  to  err  on  the  side  of  prudence 
and  safety,  by  making  it  unnecessarily  large,  than  to  attempt  the 
regular  practice  of  making  it  comparatively  small.  While,  of  course, 
on  general  principles,  small  wounds  are  less  vicious  in  every  way 
than  large  ones,  with  aseptic  precautions  and  placed  in  the  vascular 
zone,  there  seems  to  be  no  appreciable  difference  in  the  coaptation 
and  healing  properties  of  incisions  that  include  from  1/3  up  to  as 
much  as  1/2  of  the  circumference,  especially  if  the  conjunctival 
flap  is  made.  For  those  operators  who  prefer  to  transfix  the  cornea 
by  one  straight  forward  movement  of  the  knife,  with  puncture  and 
counterpuncture  in  one  plane,  and  for  beginners,  and  all  who  lack 
confidence  in  themselves,  the  larger  sections  offer  fewer  obstacles. 


CHAPTER  XII. 
ON  THE  NEWER  OPERATIONS  FOR  (H.AUCOMA. 

The  kind  of  glaucoma  referred  to  under  this  heading  is  principally 
that  designated  as  primary  (or  simple)  chronic,  which  represents 
about  I  per  cent,  of  all  eye  diseases,  although  some  of  the  measures 
discussed  are  applicable  to  other  varieties.  It  is  understood  that 
surgical  measures  are  to  be  resorted  to  in  the  treatment  of  primary 
chronic  glaucoma  only  when  less  radical  means  of  treatment  either 
have  failed  of  their  end,  or  are,  from  the  nature  of  the  case,  clearly 
out  of  the  question.  These  surgical  measures  are  divided  into  two 
great  classes,  viz.,  the  intra-ocular  and  the  extra-ocular ;  that  is,  they 
are  upon  the  globe  itself  or  upon  certain  nerve  structures  outside  of 
that  organ,  yet  closely  concerning  it.  Some  of  these  measures  have 
as  their  object  merely  the  relief  of  pain  in  blind  eyes,  but  the  great 
object  of  most  all  of  them  is  the  reduction  of  the  augmented  intra- 
ocular tension,  which  is  the  predominant  symptom  of  the  disease  in 
question,  and  that  from  which  most  of  the  other  morbid  manifesta- 
tions are  derived. 

The  intra-ocular  operations  seek  to  accomplish  their  purpose  in 
four  ways: 

First:  By  freeing  the  irian  angle  from  adhesions  between  the 
iris  and  the  cornea,  and  the  reestablishment  of  the  natural  means  of 
communication  between  the  anterior  chamber  and  the  canal  of 
Schlemm.     To  these  belong  the  operations  upon  the  iris. 

Second:  The  creation  of  channels  of  drainage  between  the 
anterior  chamber  and  the  subconjunctival  tissue.  These  include 
the  various  forms  of  anterior  sclerotomy  and  sclerectomy. 

Third:  The  making  of  a  passage  for  the  interchange  of  lluid 
between  the  anterior  chamber  and  the  perichoroidal  spaces.  The 
operations  of  Handcock,  of  Chibret,  and  of  Heine  are  in  this  class. 

Fourth:  To  make  possible  anastomoses  between  the  deep  blood- 
vessels of  the  pericorneal  region  and  those  of  the  conjunctiva  and 
subconjunctival  tissue.  This  may  be  accomplished  incidentally  by 
most  all  the  methods,  but  it  is  only  the  announced  intention  of  the 
non-perforating  form  of  sclerectomy. 

623 


624  THE    NEWER    OPERATIONS    EOR    GLAUCOMA 

The  primary  object,  then,  of  these  various  procedures  is  to 
endeavor  by  an  incising,  or  an  excising,  or  by  a  tearing  away,  to 
obtain  a  permanent,  permeable  area,  be  it  around  the  root  of  the 
iris  or  in  the  substance  of  the  sclera,  whereby  excess  of  fluid  in  the 
anterior  chambers  of  the  bulbus  may  be  carried  away  or  disposed  of. 
In  other  words,  either  the  restoration  of  normal  filtration  or  the 
substitution  of  artificial  or  vicarious  filtration  (or  absorption). 

1.  Iridectomy. — Chief  among  the  measures  for  restoration  of 
normal  filtration  is  iridectomy.  It  is  generally  conceded,  however, 
that  the  form  of  glaucoma  under  discussion  is  less  accessible  to  the 
benefits  of  iridectomy,  as  devised  by  von  Graefe  in  1856,  than  are 
the  acute  inflammatory,  primary  and  secondary  types.  This  opera- 
tion is  supposed  to  act  most  favorably  in  the  comparatively  early 
stages  of  simple  glaucoma;  as  in  those  cases  where  the  excavation 
of  the  papilla  is  not  yet  w^ell  established;  or  in  those  that  are  charac- 
terized by  considerable  hypertonicity  of  the  globe,  or  by  marked 
fluctuations  in  the  tension,  with  accesses  of  pain  and  rainbow  vision, 
by  inroads  upon  the  field  of  vision,  and  by  varying  sectors  of  sup- 
pression of  the  peripheral  light  sense.  When  the  glaucomatous 
process  has  been  insidiously  progressive,  particularly  when  the  field 
is  much  contracted,  and  the  patient  is  unable  to  read  fine  print 
connectedly,  that  is,  to  use  both  central  and  para-central  vision,  and 
when  the  changes  about  the  nerve  head  are  well  along,  iridectomy 
is  positively  contraindicated.  These  considerations  emphasize  the 
necessity  for  close  and  frequent  observations  of  the  visual  field,  for 
when  the  retraction  nears  the  center  at  some  point,  any  species  of 
surgical  intervention  is  dangerous.  Iridectomy,  as  a  single  measure, 
is  also  contraindicated  when  the  fellow  eye  has  been  iridectomized 
unsuccessfully.  Doubtless,  many  of  the  iridectomies  made  in  this 
connection  have  owed  their  value  not  to  the  cutting  or'  tearing  away 
of  the  iris,  but  to  something  purely  incidental  and  aside,  like  the 
character  of  the  scleral  cicatrix,  for  example;  or  to  incarceration  of 
the  iris;  or  to  consecutive  detachment  of  the  choroid,  which,  as  has 
been  demonstrated  by  Fuchs,  is  a  frequent  sequel  of  antiglauco- 
matous  iridectomy.  This  brings  us  to  the  second  category  of 
operations. 

2.  The  Anterior  Sclerotomies  and  Sclerectomies. — In  1862 
von  Graefe,  having  observed  how  frequently  antiglaucomatous 
iridectomy  was  followed  by  a  cystoid  cicatrix,  conceived  the  idea 
that  this  spongy  tissue,  by  permitting  the  aqueous  to  filter  slowly 


CYSTOID   CICATRIX  625 

through,  might  exert  a  favorable  influence  upon  the  intra-ocular 
tension.  Later,  however,  he  came  to  the  conclusion  that  these 
cases  gave  no  better  results  than  those  in  which  the  healing  of  the 
incision  was  prompt  and  uncomplicated.  Von  Graefe's  idea  was 
taken  up  by  De  Wecker,  about  the  year  1869,  who  declared  that  the 
scleral  scar,  after  iridectomy  for  glaucoma,  whether  actually  cystoid 
or  not,  is,  notwithstanding,  less  dense,  or  more  porous,  hence  better 
adapted  to  permit  of  certain  filtration  than  is  the  normal  sclera. 
In  consequence,  De  Wecker  came  to  believe  that  the  incision  of  the 
iris  was  superfluous,  and  that  the  scleral  incision  alone  was  the  thing. 
Stellwag,  in  1882,  promulgated  a  doctrine  somewhat  similar,  but 
thought  the  relief  of  tension  caused  by  the  incision  was  due  to  the 
section  of  the  more  external  fibrous  tissue  of  the  too  rigid  sclera, 
and  a  resultant  increase,  as  it  were,  in  the  capacity  of  the  globe, 
thus  reverting  to  the  theory  of  Guerin,  of  Lyons.  ^ 

Stellwag  was  the  first  who  essayed  to  replace  iridectomy  by 
penetrating  the  anterior  chamber  through  a  large,  oblique,  or  slant- 
ing, scleral  section — later  called  anterior  sclerotomy. 

That  a  cystoid  scar,  with  or  without  participation  of  the  iris, 
will  often  serve  to  regulate  the  intra-ocular  tension  is  beyond  question, 
but  such  a  scar  resulting  from  a  simple  incision  through  the  sclero- 
cornea  into  the  anterior  chamber  is  an  accident.  When  the  iris  is 
incorporated,  the  cicatrix  may  become  a  source  of  constant  irrita- 
tion, may  even  become  malicious,  require  other  operative  measures, 
or  be  impossible  of  amelioration  and  lead  to  loss  of  the  eye  directly 
involved,  or  to  sympathetic  inflammation  of  its  fellow.  ^loreover, 
we  all  know  how  permeable  is  such  a  scar  to  the  pyogenic  bacteria, 
and  that  it  is  never  safe  from  infection  by  pus  from  the  lacrimal 

1  Dr.  L.  Dor,  of  Lyons,  in  an  article  on  "New  Antiglaucomatous 
Operations,"  translated  by  Fox,  of  Philadelphia  {Ophthalmology,  Jan., 
1913),  tells  us  that  the  first  operation  designed  for  the  relief  of  glaucoma  was 
the  equatorial  sclerotomy  of  Guerin,  a  surgeon  of  his  city.  He  quotes  from 
Guerin's  "Traite  sur  les  Maladies  des  Yeux,"  Lyon,  1769,  the  following 
passages  in  proof  of  his  assertion :  ' '  When  the  vitreous  humor  is  in  too  great 
abundance  the  pupil  is  dilated  to  its  fullest  extent  and  has  almost  lost  its 
elasticity.  Such  patients  complain  of  a  deep,  dull  pain  at  the  back  of  the 
eye,  which  extends  sometimes  to  the  front  of  the  head,  because  the  volume 
of  the  vitreous  body  compresses  and  dilates  the  retina,  an  expansion  of  the 
optic  nerve;  the  sight  is  atlected  because  the  retina  is  injured."  After  hav- 
ing enumerated  the  medicinal  remedies  to  be  tried  in  that  sort  of  hydropsia, 
Guerin  adds:  "If  all  the  remedies  are  without  success,  one  comes  to  the 
puncture  of  the  eye  in  the  sclerotic  or  opaque  cornea.  That  pimcture  ought 
to  be  simple  and  without  much  preparation,  and  it  can  be  executed  by  a 
rather  broad  cataract  needle.  The  efifort  which  is  being  unceasingly  made 
by  the  overdilated  sclerotic  to  retitrn  to  its  natural  state  suffices  for  the  ex- 
pulsion, little  by  little,  of  the  superfluous  humor." 
40 


626  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

canal  or  the  conjunctival  sac.  Herein  lies  the  chief  objection 
to  the  inlcnlional  incorporation  of  the  iris,  as  in  the  operation  of 
iridenkleisis,  at  one  time  advocated  by  Herbert  and  by  Holth,  and 
later  by  Borthen  (of  Bergen),  under  the  name  of  iridotasis  (Knapp's 
Archives,  July,  19 11).  This  kind  of  cicatrix  is  most  effective  in 
governing  the  tension,  it  being  not  only  porous,  but  often  actually 
fistulous.  Unfortunately,  we  cannot  control  either  its  exact  makeup 
or  its  destiny. 

The  great  desideratum,  then,  is  a  more  or  less  permeable  cicatrix 
that  shall  be  safe  and  lasting.  This  can  be  obtained  by  se\eral 
methods,  though  not  always  certainly  by  any  one  of  them.  Fortu- 
nately, only  the  will  or  the  wont  of  the  patient  need  stand  in  the  way 
of  repeated  trials  of  the  simpler  and  less  harmful  measures. 

Simple  Anterior  Sclerotomy. — Among  the  least  complicated 
and  least  harmful  of  all,  perhaps,  is  simple  anterior  sclerotomy — 
made  either  from  without  inward,  somewhat  after  the  manner  of 
Stellwag,  or  from  within  outward,  after  that  of  De  Wecker.  The 
first  is  made  with  a  narrow  lance  knife,  beginning  i  1/2  to  2  mm. 
back  of  the  limbus,  and  exactly  penetrating  the  structures  in  the 
angle  of  the  anterior  chamber.  In  order  to  conform  to  modern 
conceptions  a  conjunctival  flap  should  first  be  formed  to  cover  the 
site  of  the  incision.  It  should  be  of  quadrilateral  form,  and  its 
dimensions  suf!iciently  ample  to  extend  well  beyond  the  incision 
in  every  direction.  This  insures  a  location  for  the  cicatrix  that  is 
wholly  subconjunctival,  and  its  freedom  from  obstruction  by 
epithelium  growing  into  it.  The  flap  should  be  dissected  so  that 
only  its  base  is  adherent,  and  that  to  the  opaque  zone  of  the  cornea. 
A  fine  silk  suture  is  put  into  each  of  its  two  free  corners.  The 
flap  is  not  turned  down  over  the  cornea,  nor  bunched  at  its  base, 
while  making  the  incision,  thus  obscuring  the  view  and  preventing 
accuracy;  but  an  assistant,  wearing  gloves,  holds  it  up  by  means  of 
the  threads,  but  without  making  undue  traction  upon  it,  so  that  its 
edge  is  presented  to  the  operator's  line  of  sight.  After  the  incision 
the  flap  is  simply  smoothed  out  upon  its  original  site,  or  it  may 
be  fixed  in  place  by  the  two  sutures:  or,  if  the  operator  prefers, 
he  may  make  the  flap  with  its  free  end  toward  the  cornea,  and  after 
the  incision  ])ull  it  forward,  so  as  to  cover  the  wound,  and  fasten  it 
with  a  thread  at  either  side  (see  Pig.  350).  If  the  anterior  chamljer 
is  obliterated,  recourse  may  be  had  to  the  narrow  Graefe  knife, 
and  the  incision  accomplished  ])y  ])uncture  and  counter-puncture. 


WIKRIOU    SCI.KROIO.MV  ()2-J 

not  over  6  to  cS  mm.  a])art,  exactly  through  the  irian  anj^le.  with 
emergence  somewhat  back  of  the  limhus.  Within  twenty-four 
hours  after  the  operation  it  is  best  to  begin  jjressure  massage  over 
the  centre  of  the  cornea,  or  malaxalioii,  as  it  was  called  by  its  inventor, 
Dianoux.  This  delays  closure  of  the  wound,  and  tends  to  dilate 
all  the  vessels  and  passages  in  the  front  half  of  the  glolK'. 

Ophthalmic  surgeons  are  pretty  unanimous  in  advising  against 
incisions,  or  openings  of  whate\er  nature,  of  any  considerable  extent 
about  the  base  of  the  cornea  for  chronic  glaucoma.  They  are  not 
more  efficacious  than  the  smaller  ones,  and  arc  much  more  likely 
to  be  followed,  or  attended,  by  complications.  The  iris  is  more 
apt  to  get  into  them,  and  the  vitreous  to  escape.  Again,  the 
largest  openings  are  those  most  prone  to  be  followed  by  malignancy 
in  the  nature  of  the  glaucoma.  Not  the  least  of  the  evils  consecjuent 
upon  the  more  extensive  openings  around  the  base  of  the  cornea  is 
high  astigmatism.  This  is  objectionable  for  optic  reasons,  and,  in 
these  glaucomatous  eyes,  is  a  source  of  real  danger  besides. 

Anterior  sclerotomy  may  be  repeated  over  and  over,  as  lirst 
taught  by  Snellen,  before  resorting  to  more  drastic  measures.  De 
Wecker  reopened  the  wound,  in  the  event  of  a  recrudescence,  by  a 
procedure  which  he  called  "  cicatrisotomic.''  Panas  did  the  same, 
giving  it  the  name  '' oiilctomie''  (see  page  418). 

Combined  Anterior  Sclerotomy.— In  this  form  an  excision  of  a 
portion  of  the  iris  is  added  to  the  incision.  In  many  instances, 
whether  in  connection  with  sclerotomy  or  sclerectomy,  the  iridectomy 
is  for  the  sole  purpose  of  obviating  the  possibility  of  complications 
caused  by  pernicious  healing,  in  which  the  iris  is  implicated.  If  the 
iris  falls  into  the  wound  or  prolapses,  it  is  always  best  to  excsise  a 
portion  of  it.  To  this  end  the  excision  of  a  large  section,  or  of  one 
that  comprises  the  entire  width  of  the  membrane,  is  not  necessary. 
Logetschnikow^  in  1894,  published  the  first  description  of  a  com- 
bination of  sclerotomy  with  a  small  peripheral  iridectomy,  of  the 
kind  originally  done  by  Bell  Taylor,  in  connection  with  extraction, 
and  by  Pope  for  optic  purposes,  both  in  187 1,  or  with  conservation 
of  the  sphincter  (sclerodilatorectomy).  Sometimes  Pope  contented 
himself  by  making  a  minute  incision  as  near  as  possible  to  the 
insertion  of  the  ciliary  zone,  like  Barjardi  and  Elschnig  in  extraction, 
terming  it  sclerodilatoromy.  The  incision  was,  of  course,  parallel 
with  the  limbus,  that  is,  horizontal,  when  made  a])ove.  Certain  it 
is  that  to  have  the  innermost  zones  of  the  iris  intact  after  operative 


628 


THE    NEWER    OPERATIONS    FOR    GLAUCOMA 


intervention  is  highly  desirable.  If,  for  instance,  the  corona  and 
inner  circle  can  be  spared  from  participation  in  the  coloboma,  the 
pupil  will  respond  infinitely  better  to  myotics.  It  is  a  notable  fact 
that  the  glaucoma  is  often  much  more  amenable  to  treatment  by 
myotics  after  than  before  the  surgical  interference. 

There  have  been  devised  a  number  of  other  methods  of  anterior 
sclerotomy,  some  of  which  are  already  described  in  Chapter  X. 
Place  is  here  given  only  to  those  of  later  date.  Among  the  more 
recent  is  that  of  Herbert,  of  Nottingham,  England,  formerly  of 
Bombay.     This  is  a  sclerotomy  with  a  shrinking  scleral  flap,  and 


o 


C 

Fig.  333. 


Fig.  334- 


i^  called  by  its  author  either  "wedge  isolation  method"  or  "small 
flap"  sclerotomy.  As  originally  performed,  it  was  with  a  speci- 
ally designed  very  narrow  knife.  With  this  a  small  slanting  in- 
cision was  made,  by  puncture  and  slight  cutting,  in  the  sclero- 
corneal  tissue,  beginning  two  millimeters  from  and  parallel  with 
the  limbus,  and  ending  in  the  angle  of  the  iris.  Without  with- 
drawing the  knife  two  other  cuts  were  made,  one  from  either  end  of 
the  first  one,  and  perpendicular  to  it,  up  to  and  a  little  into  the  corneal 
base.  (Fig.  S33-)  The  piece  of  sclera  thus  outlined  was  not  excised, 
but  left  to  shrink  upon  itself.  A  limited  iridectomy  was  also  made 
when  thought  best.  The  conjunctive  was  pushed  forward  before 
beginning  the  scleral  cuts,  and  the  entire  procedure  finished  beneath 
that  membrane — or  as  nearly  as  it  could  be. 


Herbert's  sclerotomy  629 

Mr.  Herbert  says  {Opli/lialniic  Record,  Novemljer,  1911):  "Two 
knives  are  now  commonly  used  in  place  of  the  narrow  Graefc — a 
keratomefor  the  primary  incision,  and  a  short,  blunt-])ointed,  narrow 
blade  for  the  lateral  cuts.  This  change  was  made  ])rimarily  in  order 
that  the  flap  might  be  placed  above  the  cornea  instead  of  at  the 
outer  side.  Bent  instruments  were  consequently  required  (Fig.  334). 
The  very  small  flaps  first  made  were  found  insuHlcient  ra])idly 
to  reduce  the  tension  of  very  hard  blind  eyes.  And  it  was  thought 
that  wider  flaps  placed  above  the  cornea  (Fig.  335)  on  account  of 
risk  of  prolapse  of  iris,  might  act  better.  This  question  of  wider 
flaps  has  not,  however,  been  fully  worked  out,  because  of  the  risks 
inseparable  from  large  incisions  in  glaucomatous  eyes,  unless 
preceded  by  Priestley  Smith's  posterior  scleral  puncture.  In  Nott- 
ingham we  do  not  now  use  a  knife  (bent  broad  needle)  wider  than 
3.5  mm.  (Fig.  334).  The  keratome  and  blunt-pointed,  narrow  knife 
(generally  Lang's  synechia  knife)  have  continued  in  use  for  the 
outer  side  of  the  eye,  because  of  the  general  feeling  against  working 
in  an  emptied  anterior  chamber  with  a  sharp-pointed  blade. 

"In  using  the  keratome  its  point  is  placed  upon  the  eyeball  4  or 
more  millimeters  aw^ay  from  the  cornea,  and  the  movable  con- 
junctiva displaced  with  it  toward  the  cornea,  the  position  of  large 
blood-vessels  being  avoided.  In  operating  at  the  outer  side,  the 
sclerotic  is  entered  2  to  2  1/2  mm.  from  the  corneal  border.  In 
operating  above,  the  distance  from  the  conjunctival  limbus  at  which 
the  sclerotic  is  entered  may  be  increased  to  3  mm.,  or  more,  if 
thought  desirable  in  the  frequent  cases  in  which  the  conjunctiva 
obviously  overlaps  the  corneal  margin  more  above  than  at  the 
sides. 

"In  eyes  with  more  or  less  shallowed  anterior  chamber,  i.e.,. 
ordinarily  in  primary  glaucoma,  the  point  in  puncturing  the  sclerotic 
is  directed  to  enter  the  chamber  immediately  in  front  of  the  iris, 
and  the  onward  movement  is  slow.  The  flap  is  thus  made  as  long 
as  practicable,  measured  at  the  inner  surface  of  the  cornea. 
But  it  is  not  easy  always  to  hit  off  the  exact  level  of  entry  into  the 
chamber  correctly.  One  frequently  finds  that  the  knife  engages  in 
the  base  of  the  iris,  detaching  it.  This  is  satisfactory  evidence  that 
the  puncture  has  been  made  at  least  deep  enough,  and  in  some  cases 
a  small  iridodialysis  may  be  useful,  serving  instead  of  a  peripheral 
buttonhole  iridectomy.  Evidence  of  pain  experienced  by  the  patient 
often  indicates  that  the  point  is  penetrating  uveal  tissue  bcforejt 


630  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

becomes  visible  in  the  angle  of  the  chamber.  It  is  important  to 
locate  the  point  of  the  knife  as  early  as  possible,  in  order  to  correct 
possible  errors.  A  side-to-side  or  forward  and  backward  rocking 
of  the  blade  may  enable  one  to  detect  the  point  hidden  by  iris.  The 
blade  may  have  to  be  withdrawn  a  little  to  disengage  it  from  the  iris, 
and  passed  on  again  closer  to  the  cornea,  in  order  to  avoid  making 
rather  a  large  iridodialysis. 

"If,  on  the  other  hand,  the  knife-point  be  found  entering  the 


u 

s 


chamber  somewhat  superficially,  this  can  usually  be  corrected  by 
partial  withdrawal  of  the  knife,  without  much  loss  of  aqueous, 

"The  narrow  knife  for  the  side  cuts  is  introduced  on  the  fiat, 
well  into  the  chamber,  but  not  usually  as  far  as  the  pupillary  margin 
(Fig.  335B).  It  is  turned  forward  at  one  end  of  the  primary  incision, 
thus  emptying  the  chamber,  unless  it  is  already  emptied. 

"Cutting  the  second  lateral  incision  is  a  little  more  tedious,  as 
the  flap  is  now  less  fixed.  The  drag  upon  the  eye  in  the  making  of 
this  second  incision  produced  an  escape  of  vitreous  in  one  buphthal- 
mic  infant  upon  which  I  operated.  The  two  incisions,  of  course, 
extend  considerably  beyond  the  level  of  the  limbus  at  the  posterior 
surface  of  the  cornea. 

"In  a  few  of  my  early  cases  iridectomy  was  added,  sometimes 


Herbert's  sclerotomy  631 

unnecessarily.  Since  then  I  have  not  found  it  necessary  at  all, 
except  in  cases  of  adherent  leucoma. 

"I  have  performed  up  to  date  fifty-four  operations  in  this  country, 
as  above  described,  for  glaucoma,  primary  or  secondary.  To  the 
best  of  our  knowledge,  neither  Mr.  Laws  nor  I  have  failed  by  this 
method  to  relieve  the  tension  in  any  case  of  primary  glaucoma 
still  retaining  any  vision,  except  in  one  case.  And  in  this  one  case 
the  vision  was  only  hand  movements.  But  in  hard  blind  eyes, 
congested  and  painful,  I  have  had  to  be  satisfied  usually  with  relief 
of  pain  and  congestion,  the  tension  being  only  tem])orarily  or 
partially  reduced. 

"The  main  idea  underlying  the  method  is,  as  with  my  'wedge' 
operation,  that  of  shrinkage  of  isolated  tissue,  such  as  takes  place 


Fig.  336. 

with  grafts.  The  small  flap  presents  a  considerable  bulk  of  tissue, 
normally  vascular,  which  must  remain  very  poorly  nourished  for  a 
time,  mainly  through  its  basal  attachment  to  non-vascular  cornea. 
Another  means  of  reducing  the  nutrition  of  the  flap,  which  I  car- 
ried out  once  or  twice  in  India,  is  to  divide  the  flap  into  two 
(Fig.  336  B)." 

Herbert  mentions  the  following  points  of  importance  in  connec- 
tion with  this  operation: 

1.  The  strip  of  tissue  must  be  quite  close  to  the  limbus. 

2.  Any  increase  in  the  length  of  the  strip  of  tissue  tends  to  the 
formation  of  a  fistula,  for  the  longer  the  wedge,  made  as  directed, 
the  deeper  it  is. 

3.  The  wedge  must  not  be  too  broad  superficially. 

4.  There  must  be  a  long  adherent  conjunctival  flap. 

5.  These  operations  are  unsuited  for  cases  of  secondary  glaucoma 
in  which  vitreous  is  likely  to  enter  the  wound,  since  vitreous  in  the 
wound  prevents  filtration. 

Bishop  Harman,  of  London  [The  Ophthahno scope,  191 1,  No.  11) 

has  invented  a  special  instrument  for  making  the  Herbert  incisions. 

The   next   sclerotomy    to   be  alluded  to  is  that  of  Bjcrrum,  of 


632  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

Copenhagen  (L'Opht.  Proviuc,  March,  1909),  which  he  makes  as 
follows:  The  knife  is  a  small  Graefe  model,  narrow  of  blade, 
but  thick  at  the  back,  and  near  the  point  is  double-edged.  He 
stands  behind  the  patient's  head  for  the  right  eye,  and  makes  the 
sclerotomy  downward ;  and  at  the  left  side,  and  with  upward  sclerot- 
omy, for  the  left  eye.  In  beginning  the  puncture  the  conjunctiva  is 
displaced  somewhat  toward  the  limbus  with  the  point  of  the  knife 
before  entering  the  sclera.  As  soon  as  the  point  appears  in  front  of 
the  iris,  at  the  angle  of  the  chamber,  it  is  directed  toward  the  lower 
circumference  of  the  chamber  (to  the  upper,  if  left  eye),  keeping 
the  blade  close  down  to  the  iris,  managing  to  catch  the  iris  on  the 
point  of  the  knife  just  before  making  the  counterpuncture.  Thus 
the  iris  follows  slightly  the  knife.  The  point  of  the  knife  emerges 
from  the  conjunctiva  3  to  6  mm.  (?)  back  of  the  limbus.  Usually 
the  aqueous  escapes  here,  raising  a  bleb  of  conjunctiva.  The 
knife  is  held  still  while  the  aqueous  runs  out,  then  slowly  withdrawn, 
with  a  sawing  movement,  by  which  the  sections  are  somewhat 
extended.  At  the  site  of  the  counterpuncture  regularly  appears  a 
solution  of  continuity  in  the  iris,  which  looks  like  an  iridodialysis. 
The  pupil,  in  consequence,  is  somewhat  displaced  toward  the 
point  of  puncture,  and  becomes  an  oval,  with  its  long  axis  parallel 
to  the  section.  If  the  tension  does  not  become  normal  in  one  week 
afterward,  Bjerrum  has  recourse  to  compressive  massage  at  the 
center  of  the  cornea,  through  the  lid  as  a  supplementary  measure. 
By  this  massage,  beginning  five  to  seven  days  after  the  sclerotomy, 
and  practising  it  for  only  one  minute  daily  for  a  week,  Bjerrum 
has  reduced  the  T  to  normal  and  seen  it  remain  so  as  long  as  the  case 
could  be  followed.  He  adds,  however,  that  in  but  few  cases  can  he 
dispense  with  myotics,  even  after  the  operation.  This  form  of 
sclerotomy  is  less  of  an  operation  than  either  iridectomy,  iridencleisis 
or  perforating  sclerectomy. 

Grill-like  Sclerotomy  of  WicJierkiewicz. — In  Ophthalmology,  July, 
1913,  is  the  following  description  by  this  eminent  specialist  of  his 
novel  operation,  which  he  has  named  as  per  the  caption.  The 
article  is  translated  by  Zimmermann,  of  Milwaukee. 

"My  method  was  intended  for  those  forms  of  glaucoma  in  which 
iridectomy  and  anterior  sclerotomy  fail,  viz.,  glaucoma  simplex,  and 
those  in  which  operations  had  no  lasting  results.  These  are  certain 
forms  of  inflammatory  glaucoma,  in  which  the  inflammatory 
symptoms  were  favorably  influenced  by  iridectomy,  but  in  which 


WICHERKIEWICZ'    SCLEROTOMY  633 

vision  gradually  deteriorated,  then  secondary  glaucoma,  in  which 
the  anterior  outlets  cannot  be  approached.  In  other  words,  that 
part  of  the  eye,  which  so  far  has  not  received  suflicient  attention,  viz., 
the  sclera,  ought  to  be  made  the  object  of  treatment. 

"Frequently  the  sclera,  especially  of  older  persons,  feels  very  rigid 
to  the  touch,  and  examinations  of  enucleated  eyes  confirmed  this 
by  the  increased  thickness  of  the  sclera.  If  the  sclera  becomes  rigid 
it  loses  its  elasticity  and  forms  a  resistance  in  increased  intraocular 
tension,  which  even  in  physiological  fluctuations  must  act  on  the 
vascular  and  even  more  on  the  nervous  parts  of  the  visual  organ. 
Then  another  element  may  play  a  role.  The  rigid  sclera  may 
occasionally,  as  will  be  set  forth  below,  close  the  communication 
between  the  suprachoroidal  and  Tenon's  spaces,  which  perhaps 
participates  in  the  excretion.  The  vessels  penetrating  the  sclera, 
especially  the  vorticose  veins,  are  surrounded  by  lymphatic  sheaths, 
which  connect  both  spaces.  By  accumulation  of  connective  tissue, 
in  rigidity  of  the  sclera,  these  communications  are  constricted  or 
closed,  which  may  decidedly  contribute  to  the  increase  of  intraocular 
tension.  If  this  be  the  case,  multiple  recticular  incisions  of  the  rigid 
sclera  to  its  deepest  layers  must  make  it  more  expansible,  lower  the 
pressure  exerted  by  it  and  prevent  a  stasis  of  lymph  in  the  supra- 
choroidal space. 

"It  must,  however,  be  emphasized  that  intraocular  tension  and 
rigidity  of  the  sclera  do  not  always  coincide,  but  may  frequently 
show  an  opposite  behavior.  If  intraocular  tension  is  increased  and 
the  rigidity  of  the  sclera  diminished,  the  increase  of  tension  will  be 
indicated  by  the  tonometer,  but  not  by  the  palpating  finger.  Hence 
follows  that  the  tonometer  is  not  always  a  reliable  gauge  as  to  the 
success  of  an  antiglaucomatous  operation  in  rigidity  of  the  sclera. 
We  may  in  those  cases  in  which  there  is  no  decided  increase  of  tension 
and  still  failure  of  central  and  peripheral  vision  with  excavation  of  the 
disc  recognize  the  rigidity  of  the  sclera  as  the  only  cause  of  it.  Here 
chiefly  my  operative  method  proves  ^•ery  useful,  perhaps  unique, 
preventing  the  further  deterioration  of  vision. 

^^  Operation. — After  instillation  of  cocain  a  subconjunctival  in- 
jection of  a  I  per  cent,  solution  of  cocain  with  adrenalin  is  made 
into  the  upper  temporal  region  of  the  eyeball.  While  an  assistant 
rotates  the  eyeball  far  downward  with  a  sharp  hook  inserted 
above  the  cornea,  I  made  a  long  meridional  incision  through  the 
conjunctiva.     The  subconjunctival  tissue  is  lifted  uj)  with  two  pairs 


634  THE    NEWER   OPERATIONS   EOR   GLAUCOMA 

of  forceps  and  incised  successively  to  the  sclera,  the  bleeding  being 
controlled  by  instillations  of  adrenalin.  After  the  sclera  is  largely 
exposed  I  make  with  von  Graefe's  knife  from  four  to  six  meridional 
incisions,  10  to  12  mm.  long,  into  the  sclera,  and  as  many  cross- 
sections,  as  far  back  as  possible.  If  the  sclera  is  very  thick  some  of 
the  incisions  are  deepened,  but  only  from  2  to  3  mm.  long,  as  far  as  to 
the  chorioid.  After  irrigations  with  salt  or  boric  acid  solutions  and 
Imally  electragol,  the  wound  of  the  conjunctiva  and  Tenon's  capsule 
is  closed  with  a  few  firm  sutures  and  a  bandage  applied  for  from  one 
to  two  days  'The  patient  is  not  confined  to  bed.  After  from  four 
to  five  days  the  sutures  are  removed.  Generally  the  intraocular 
tension  is  considerably  diminished  immediately  after  the  operation, 
but  more  so  if  the  eye  is  massaged,  which  always  ought  to  be  done 
before  applying  the  dressing. 

"Disagreeable  accidents  during  the  operation,  as  prolapse  of 
the  chorioid,  cutting  into  it  or  the  retina,  prolapse  of  vitreous,  did 
not  occur  in  the  whole  series  of  100  cases.  This  does  not  mean 
that  they  may  not  occur,  but  I  believe  that  they  will  not  influence 
the  effect  of  the  operation.  However,  they  ought  to  be  avoided, 
and  the  beginner  may  place  the  sutures  before  making  the  scleral 
incisions. 

"While  I  devised  this  operation  chiefly  for  glaucoma  simplex,  it 
was  also  performed  in  other  cases.  I  became  convinced  that  the 
operation  acts  favorably  whenever  glaucomatous  symptoms  depend 
directly  upon  the  changed  condition  of  the  sclera,  glaucoma  simplex, 
or  are  essentially  influenced  by  it,  inflammatory  glaucoma,  if  in 
spite  of  regular  iridectomy  and  in  consideration  of  various  etiological 
elements  which  influence  glaucoma  after  disappearance  of  the 
inflammatory  symptoms,  vision  deteriorates.  The  operation  was 
performed  in  glaucoma,  with  iritis  and  iridocyclitis,  if  punctures 
did  not  help,  and  iridectomy  was  contraindicated  for  some  reason  or 
other,  also  in  glaucoma  as  a  preliminary  operation  to  extraction,  and 
in  hemorrhagic  glaucoma,  which  generally  takes  a  malignant  course 
after  iridectomy.  Keratoconus  and  keratoglobus  in  some  cases  were 
benefited  by  the  operation  as  shown  by  improvement  of  vision  and  de- 
crease of  myopia  and  irregular  astigmatism.  Also  the  glaucomatous 
symptoms  produced  by  dislocation  of  the  lens  into  the  vitreous,  in 
rigidity  of  the  sclera,  were  fa\-oral)ly  intluenced  by  this  sclerotomy." 
Van  Lint's  T-shaped  Sclerotomy  [La  Cliniquc  OphthalmoJog- 
i(ju(\  July  ID,  1913). — Since    the    i)eginning  of  the  year  1912,  Van 


beard's  anterior  sclerotomy  635 

Lint,  of  Brussels,  has,  in  all  forms  of  <j;laucoma,  employed  only  his 
own  operation  which  he  calls  "  T-Shaped  Sclerotomy. ''' 

Technic.—i.  The  eon junclival  flap:  Jiuision  of  the  conjunctiva, 
close  to  the  limbus,  around  the  upper  half  of  the  cornea.  Free  dis- 
section, down  to  the  bare  sclera,  and  extending  at  least  a  centimeter 
upward  from  the  cornea.  A  moderately  fine  silk  suture  is  passed 
through  the  adherent  conjunctiva  at  either  side  of  the  cornea,  2  or 
3  mm.  from  the  edge  of  the  opening,  and  close  to  the  limbus.  Each 
thread  is  carried  upward,  passed  beneath  the  detached  conjunctiva, 
and  brought  out  fully  10  mm.  from  the  point  of  introduction,  so  that 
when  tied  the  loosened  conjunctiva  will  be  drawn  over  the  upper 
fourth  of  the  cornea.  2.  Concenlric  section  of  the  sclera  (horizontal 
branch  of  the  T) :  Incision  with  the  lance  keratome  precisely  as  for 
antiglaucomatous  iridectomy,  save  that  the  point  of  entrance  in  the 
sclera  is  2  to  2.5  mm.  from  the  limbus  instead  of  i  to  1.5  mm.  Because 
of  its  entrance  so  far  back  the  knife  does  not,  as  a  rule,  pass  in  front 
of  the  iris,  but  engages  that  membrane,  at  its  periphery,  producing 
an  iridodialysis.  3.  The  iridectomy:  At  one  time  Van  Lint  contents 
himself  with  the  iridodialysis,  at  another  he  makes  an  iridectomy, 
either  small  and  well  outward,  or  one  that  includes  the  entire  width 
of  the  iris.  The  extent  of  excision  is  greater  in  proportion  as  the 
glaucoma  is  more  acute.  The  conditions  are  such  that  it  is  best  to 
use  iris  forceps  whose  teeth  project  from  the  concavities  of  the  jaws 
rather  than  from  their  convexities.  4.  Radiate  sclero-corneal  sec- 
tion (vertical  branch  of  the  T):  One  branch  of  a  pair  of  slender, 
straight  scissors  is  inserted  at  the  middle  of  the  scleral  incision,  and 
pushed  sufficiently  far  into  the  anterior  chamber  to  include  i  to  1.5 
mm.  of  the  cornea  in  the  one  snip  radial  cut  now  made.  5.  Tying 
the  sutures:  An  assistant  draws  the  conjunctival  flap  down  with 
forceps,  to  insure  complete  covering  of  the  wound,  while  the  surgeon 
knots  and  cuts  off  the  threads.. 

According  to  its  originator  the  mode  of  action  of  the  measure  is 
fourfold:  (a)  The  large  conjunctival  flap,  (b)  the  iridectomy,  (c) 
the  expansion  of  the  rigid  sclera  and  the  opening  of  Schlemm's 
canal  andFontana's  spaces  resulting  from  the  T-incision,  and  (d)  the 
subconjunctival  filtration  and  increased  secretion  of  aqueous,  con- 
stituting the  principal  factors. 

Beard's  Anterior  Sclerotomy,  or  Complete  Section  of  the  Scleral 
Flap,  but  Leaving  a  Broad  Conjunctival  Bridge,  and  FoUou'ed  by 
Pression   Massage. — For  a   number  of  years  the  author  has  been 


6^.6 


THE    NEWER    OPERATIONS    FOR    GLAUCOMA 


faithfully  served  by  a  method  that  begins  just  where  that  of  De 
Wecker  ended.  It  has  never  before  been  described  in  print,  and  its 
technic  is  here  given.  Eserin  and  cocain.  Puncture,  and  counter- 
puncture,  not  more  than  8  mm.  apart  in  the  opaque  cornea,  by  means 
of  a  very  narrow  Graefe  knife  (Fig.  337).  The  edge  of  the  knife 
is  turned  backward  into  the  iridic  angle  and,  bv  slow  and  cautious 


Fig.  337. — Beard's  method  of  anterior  sclerotomy.     Puncture  and  counter-puncture. 
It  begins  where  the  De  Wecker  operation  ends. 


sawing  movements,  keeping  the  edge  turned  ever  backward,  a  crescent 
of  the  sclera  is  included  in  the  section.  This  crescent,  which  should 
be  from  1.5  to  2  mm,  wide  at  its  middle,  is  entirely  divided,  care  being 
exercised  to  leave  undivided  as  much  as  possible  of  the  included  con- 
junctiva (Fig.  338).  One  endeavors,  by  every  means,  to  avoid  a 
prolapse  of  the  iris.  To  this  end  a  trained  aid  holds  the  lids  apart 
with  retractors,  the  fixation  forceps  are  closely  watched  to  see  that 
they  neither  press  nor  pull,  and  the  patient's  apprehensions  are 
quieted  by  gentle  words.     The  aqueous  is  allowed  very  slowly  to 


j5i:ard  s  sclerkctomy 


637 


escape  before  completing  the  scleral  section.  A  ])rola])Sc  under  the 
existing  conditions  could  not  be  adequately  dealt  w  ith,  and  an  iridec- 
tomy would  be  undesirable  in  view  of  the  ])ossible  need  of  the  effect 
of  myotics  at  a  later  period.  To  insure  a  minimum  of  incision  of 
the  conjunctiva  this  membrane  is  pulled  up  and  loosened  with 
smooth-jawed  forceps,  all  about  the  site  of  the  field  of  operation 
before  bctrinninti;  the  scleral  section. 


Fig.  338. — Beard's  Anterior   Sclerotomy.     The  scleral  incision    completed,  leaving 
the  conjimctiva  xmdivided. 

Pression  massage  is  begun  sixteen  to  twenty-four  hours  after  the 
operation.  Steady  pressure  is  made  over  the  center  of  the  cornea 
through  the  lower  lid,  the  patient  looking  strongly  downward,  till 
an  escape  of  aqueous  raises  a  bleb  of  conjunctiva,  about  the  incision, 
and  the  tension  is  greatly  reduced.  This  is  repeated  daily  until  a 
filtration  cicatrix  is  obtained.  The  pressure  should  not  be  suddenly 
applied  lest  a  prolapse  of  the  iris  ensue.  Moreover,  in  releasing 
the  pressure,  unless  it  is  done  very  slowly,  there  will  be  a  sudden 
twinge  of  pain  that  will  cause  the  patient  to  start  back.     In  several 


638 


THE    NEWER    OPERATIONS    FOR    GLAUCOMA 


instances  I  have  taught  the  patient,  or  some  member  of  the  same 
household,  how  to  make  the  massage,  so  that  they  might  have 
recourse  to  it  indefmitely.  Some  of  those  operated  upon  are 
clever  enough  to  at  once  detect  the  a])pearance  of  symptoms  of 
hypertension. 

The  operation  is  chiefly  apijlicable  to  simple  chronic  glaucoma^ 
inclusive  of  the  juvenile  form.  Points  to  be  emphasized  are  that  the 
scleral  incision  be  not  of  too  great  length,  that,  as  soon  as  puncture 
and  counterpuncture   are  made,  the  edge  of  the  knife  be  directed 


Fig.  339. — Lagrange's  sclerectomy.     The  incision. 


exactly  into  the  iridic  angle,  and  that  no  pressure  be  brought  to 
bear  upon  the  globe  at  any  stage  of  the  procedure.  Another  requi- 
site is  that  the  iris  should  be  thoroughly  under  eserin  when  the  opera- 
tion is  begun,  lioth  eyes  are  bandaged,  and  over  all  a  Ring  bin- 
ocular ])rotective  mask.  In  the  event  of  a  recurrence  of  overtension 
myotics  are  resorted  to.  These  failing,  the  same  measure  may  be 
repeated,  or  some  other  be  tried. 

Sclerectomy. — This  is  of  two  kinds,  perforating  and  non-perforat- 
ing. As  regards  the  newer  antiglaucomatous  measures,  perforating 
sclerectomy  originated  with  Lagrange,  of  Bordeaux  {Arch,  irophl.^ 
Aug.,  \()o()). 


LAGRANGE  S    SCLKRKCTOM V 


639 


Pcrjord/iiii^  sdcrolomy  of  JAi<^r(ini^(',  cither  simi)lf  or  comhincd 
with  peripheral  or  ordinary  iridectomy,  is  ])errormed  as  follows: 
After  eserinization,  an  obli([uc  incision  is  made  through  the  sclera 
by  means  of  a  narrow  (iraefe  knife,  and  a  larL^n-  conjunctival  llap 
secured.  This  is  accomplished  by  makin<,'  ])unclure  and  counter- 
puncture  just  ])ack  of  the  apparent  corneal  mar<^in  with  the  knife, 
and,  as  soon  as  its  edge  reaches  the  upper  limit  of  the  anterior 
chamber,  it  is  turned  backward  and  brought  out  through  the  sclera 
obliquely,  then  farther  back  beneath  the  conjunctiva,  so  as  to  make  a 
large  flap  of  that  membrane.  The  conjunctival  flaj)  is  then  turned 
back  over  the  cornea,  and  the  fragment  of  sclera  that  was  left  at- 
tached to  the  cornea  is  cut  squarely  off  by  means  of  a  pair  of  delicate, 
curved  scissors.  ( )n  some  occasions,  of  late,  Lagrange  has  used  the 
Holth  punch. 

The  accompanying  ilhistrations  (Figs.  340  and  341),  taken  from 


Fig.  340. — Lagrange's  sclerectomy.     'J  he  dotted  lines  show  formation  of 


incisions . 


an  article  kindly  furnished  me  by  Lagrange  himself,  will  suflicc  better 
than  a  descripion  to  make  clear  the  different  steps  of  the  operation. 

Lagrange  invites  attention  to  the  fact  that  the  knife  grazes  the 
root  of  tlie  iris  in  a  way  that  effectually  sections  the  attachment  of 
the  ciliary  muscle,  which  is  equivalent  to  opening  the  suprachoroid- 
eal  spaces.  And  that  the  scleral  excision  is  narrow  and  long,  in 
that  sense  corresponding  to  the  angle  of  filtration,  is  also  to  be 
noted.  Thus  is  obtained  a  fistulous  angle  instead  of  the  defective 
fiUraiion  one. 

The  simple  measure  is  contraindicated  if  the  hypertension 
exceeds  +  2.  For  such  cases  iridectom}-,  of  the  ordinary  kind,  is 
combined  with  it.  If  iridectomy  is  included  when  the  operation  is 
for  simple  chronic  glaucoma,  it  is  of  the  very  limited  peripheral 
type. 


640 


THE    NEWER    OPERATIONS    FOR    GLAUCOMA 


When  combined  willi  iridectomy  the  latter  follows  the  sclerectomy 
— -not  the  primary  incision.  Lagrange  insists  that  the  incision 
extend  not  too  far  back,  and  that  the  excision  be  exactly  over  the 
irian  angle.  The  conjunctival  llap  is  now  replaced  and  a  bandage 
applied. 

In  order  to  obtain  an  adequate  conjunctival  flap  in  the  Lagrange 
operation,  I  have  been  accustomed  to  make  the  formation  of  this 
important  feature  the  first  step.  In  this  way  the  conjunctiva  can  be 
loosened  even  into  the  opaque  zone  of  the  cornea,  so  that  the  portion 
of  sclera  to  be  excised  is  entirely  uncovered.  In  making  the  incision 
the  flap  is  held  by  a  gloved  assistant  with  its  edge  in  line  with  the 
operator's  eyes.  Of  course,  two  sutures  have  been  put  into  the 
flap,  and  it  is  by  these  that  the  assistant  holds  it. 


Fig.  341. — Lagrange's  sclerectomy.     The  excision 


The  Lagrange  operation  has  been  modified  by  a  number,  among 
whom  are  Holth,  Dor,  Coppez,  and  Jacqueau. 

Holth  (Med.  Soc.  of  Christiana,  1908)  embodies  the  idea  of 
Lagrange  in  his  operations.  Instead,  however,  of  the  big  incision 
made  with  a  knife,  which  sometimes  leads  to  rupture  of  the  zonule 
and  to  expulsive  hemorrhage,  he  chooses  the  6  mm.  width  lance 
with  which  he  made  most  of  his  iridencleises.  In  the  use  of  this  he 
had  never  seen  either  of  these  accidents,  although  some  of  the 
operated  eyes  had  had  T  of  100  mm.  of  mercury.  He  first  made  the 
sclerectomy  by  two  converging  snips  of  the  scissors,  then  bethought 
him  that  a  punch  would  serve  better.  After  trying  Stephenson's 
capsule  punch,  and  that  of  Vacher  for  iridocapsulectomy,  both  of 
which  were  too  weak,  he  had  made  two  analogous  instruments 
something  after  the  model  of  a  forceps-gouge  for  trepanation  of  the 
cranium. 


IIOLTII  S    SCLERECTOMY 


^>4 


Tcrhnic.  Puncture  of  conjunctiva  lo  mm.  and  of  sclera  2  1/2  mm. 
from  limhus.  and  liberation  of  the  conjunctival  llaj).  Or  this  llap 
may  be  J'lrst  fashioned  and  the  scleral  incision  be  made  afterward. 
The  conjunctival  flap  is  seized  with  the  roughened  forceps  and  lifted 
on  to  the  double  hook,  and  drawn  down  o\er  the  cornea  to  expose 
the  scleral  wound.  The  anterior  sclerectomy  is  (piickly  made  with 
the  punch,  the  double  hook  holdintj;  the  conjunctival  flap  is  then 
given  to  an  assistant,  while  the  o])erator  makes  the  little  peripheral 
iridectomy  that  tends  to  ])revent  hernia  or  prolapse  of  the  iris. 
Ordinary  iridectomy  is  made  in  cases  of  corneal  or  lenticular  opacity, 


Fig.  342. — Lagrange's  sck-rcLtomy.  The  fashioning  of  the  conjunctival  flap  has 
been  the  first  step  of  the  operation,  and  sutures  placed,  leaving  long  ends  and  loops 
of  thread.  As  soon  as  the  sclerectomy  is  completed  the  llap  is  made  a  safe  covering 
for  the  defect  by  tying  the  threads. 

or  when  the  iris  prolapse,  otherwise  the  peripheral  form,  but  always 
before  the  sclerectomy.  The  conjunctival  flap  is  ])ut  in  place  with 
the  spatula.  All  the  sclerectomies  of  the  posterior  lip  he  made  with 
Vacher's  punch.  INIost  of  them,  howe\er,  were  of  the  anterior  lip. 
In  order  to  obtain  a  true  hltration  cicatrix,  with  edema  of  the 
conjunctiva,  etc.,  no  part  of  the  conjunctiva  must  be  included  with 
the  sclera  in  the  bite  of  the  punch.  If  the  scleral  opening  is  not 
wholly  covered  by  the  conjunctiva,  it  will  cicatrize  in  the  ordinary 
manner,  and  the  result  be  ;///. 
41 


642 


THE    NEWER    OPERATIONS    FOR    GLAUCOMA 


Trephining  of  tlic  Sclera,  or  Trepanation. — Fergus,  of  Glasgow 
{Brit.  Med.  Jour.,  Oct.  21,  1909)  was  the  first  to  think  of  making 
the  sclerectomy  by  means  of  a  circular  or  revolving  trephine.  His 
operation  was  a  sort  of  combinotion  af  sclerectomy  and  cyclodialysis. 
He  first  made  a  conjunctival  flap,  base  at  the  limbus,  turned  it 
down  over  the  cornea,  and,  with  a  Bowman  trephine,  or  an  instru- 
ment modeled  after  it,  excised  a  disc  from  the  sclera  adjoining  the 
cornea.  He  then  passed  a  spatula  through  the  opening,  between 
sclera  and  root  of  iris,  into  the  anterior  chamber.  The  flap  was 
replaced  without  suturing.     For  history  see  page  426. 

Elliot's  Method.— {The  Ophthalmoscope,  Dec.  i,  1909.)  The 
name  of  Colonel  Robert  H.  Elliot,  of  the  British  Army  Medical 
Service,  formerly  stationed  in  Madras,  India,  has,  because  of  his 
enormous  experience  with  trepanation  for  glaucoma,  become  as  much 
identified  with  the  procedure  as  has  that  of  his  colleague,  Major  Smith, 
with  intracapsular  extraction.  The  trephine  he  uses  is  a  modifica- 
tion of  the  one  used  by  Fergus,  and  was  suggested  by  Mr.  Sidney 


Fig.  343. — Stephen- 
son's trephine. 


Fig.  344. — Pusey's 
trephine . 


P'lG.  345. — Bow- 
man's trephine. 


IVMM      2  MM 

Fig.  346. — Elliot's 
later  trephine. 


Stephenson,  of  London.  INIajor  Elliot  and  his  associates  up  to 
July,  191 1,  had  performed  the  operation  in  the  Government  Hospital 
at  Madras  in  over  400  cases.     The  number  now  is  about  1000. 

Technic. — A  large  triangular  llaj)  of  conjunctiva  is  dissected  up 
from  above  the  cornea,  the  attached  base  of  the  triangle  lying  at  the 
sclero-corneal  margin.  It  is  most  essential  that  this  llap  should  be 
dis.sected  right  uj)  to  the  limbal  attachment  of  the  conjunctiva;  to- 


Elliot's  trepiunatiox  643 

ensure  this,  il  is  retlected  on  to  the  cornea  and  the  dissection  is  jjro- 
ceeded  with  until  the  rounded  edge  of  the  liml^us  can  be  seen  over- 
hanging the  surrounding  scleral  tissue.  But  in  old,  long-standing 
cases  it  cannot  always  be  obtained,  and  these  are  precisely  the  cases 
in  which  there  may  be  difTiculty  in  entering  the  chamber  on  account 
of  adhesions  at  the  iridocorneal  angle;  we  are  then  in  danger  of 
being  confronted  with  a  complicated  operation  and  with  possible 
ultimate  failure.  When  such  cases  are  met  with,  the  surgeon  should 
dissect  right  into  the  corneal  substance,  splitting  its  layers,  till  he  is 
well  over  the  limbus  margin,  and  can,  therefore,  rely  on  the  trephine 
cutting  straight  into  the  chamber.  Before  the  trephine  is  applied 
to  the  sclera,  the  area  selected  foi;  its  application  should  be  care- 
fully cleaned  of  connective- tissue  tags  attached  to  the  flap;  this  can 
be  easily  done  by  dissection  with  the  scissors  points.  If  the  pre- 
caution is  neglected,  the  flap  will  be  drawn  into  the  instrument  as 
it  works,  and  will  be  buttonholed  or  otherwise  seriously  damaged. 
The  spot  selected  for  trephining  should  be  as  close  to  the  limbus  as 
possible.  If  this  cardinal  rule  is  disobeyed,  two  dangers  confront 
the  operator:  (i)  He  is  much  more  likely  to  have  an  escape  of  vitre- 
ous than  if  he  obeyed  the  rule,  and  (2)  he  will  probably  fail  to  enter 
the  chamber  with  his  trephine  and  will  have  to  burrow  his  way  into 
it  by  the  aid  of  a  spatula  or  other  instrument.  In  so  doing  he  will 
probably,  if  not  certainly,  injure  the  ciliary  body.  The  trephine  is 
used  with  quick,  light  movements,  and  care  is  taken  that  its  first 
application  serves  to  bite  into  the  sclera,  before  it  is  raised  to  see 
the  progress  made.  Once  a  clean  ring  is  thus  started,  it  is  easy  to 
replace  the  trephine  in  it  again.  In  his  early  cases  the  surgeon  feels 
the  need  of  frequently  removing  the  trephine  to  mark  the  progress 
made,  but  he  soon  learns  to  know  when  he  is  "through."  There 
are  several  points  to  guide  him  as  to  this:  (i)  The  moment  the 
chamber  is  tapped,  aqueous  wells  up  alongside  the  instrument 
and  mingles  in  streaks  with  the  surrounding  blood.  (2)  There 
is  a  curious  sucking  sensation  the  moment  the  trephine' s  work 
is  done.  And  (3)  the  patient  often  indicates  the  completion  of  the 
section  by  a  slight  movement  due  to  the  pain  (very  bearable)  inflicted 
at  this  moment.  There  is  a  likelihood  that  the  surgeon  will  leave 
his  disc  of  sclera  attached  at  one  point,  and  this  should  be  at 
the  scleral  side,  A  snip  with  a  pair  of  sharp  iridectomy  scissors 
separates  this  attachment.  If  the  trephine  is  very  sharp  even  this 
is  unnecessary,  as  the  disc  is  cut  out  clean.  It  is  advisable  while 
trephining  to  lean  little  on  the  corneal  edge  rather  than  on  the 


644  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

opposite  one.  In  this  way  we  make  sure  of  entering  the  chamber  as 
far  forward  as  possible.  The  beginner  finds  a  Httle  diflicuhy  in 
keeping  his  trephine  to  one  spot,  and  indeed  one  of  our  pupils  at 
first  seemed  (|uitc  unable  to  do  so;  even  the  expert  finds  a  little 
difficulty  if  working  with  a  very  blunt  trephine.  Considerable 
assistance  is  obtained  by  seizing  the  trephine  low  down,  close  to  the 
eye,  in  the  grip  of  a  ])air  of  conjunctival  forceps,  and  thus  steadying 
the  cutting  edge  of  the  instrument.  We  have  tried  trephines  of 
various  sizes,  and  have  been  favored  with  a  very  large  amount  of 
advice  on  this  subject  from  various  parts  of  the  world.  A  2.5  mm. 
(diameter  measurement)  cutting  edge  has  been  discarded  as  un- 
necessarily large;  on  the  other  hand,  a  i  mm.  trephine  introduces  a 
complication  in  the  decided  difficulty  involved  in  dealing  with  the 
iris  through  so  small  an  aperture.  The  choice  lies  then  between  a 
1.5  mm.  and  a  2  mm.  instrument,  and  our  inclination  is  toward 
the  latter.  On  several  occasions,  when  working  wdth  a  small 
trephine,  the  disc  slipped  into  the  chamber  and  was  lost  to  view;  on 
all  occasions  it  was  easily  enough  recovered  by  excising  a  portion  of 
iris  and  then  washing  out  the  chamber  with  a  McKeown's  irrigator. 
The  disc  at  once  showed  in  the  hole  and  was  easily  picked  out  with 
forceps.  Later  Elliot  reported  that  he  made  no  attempt  to  recover 
the  disc,  as  it  was  aseptic  tissue  and  could  do  no  harm.  It  sometimes 
happens  that  the  iris  bulges  into  the  aperture  the  moment  the  disc 
is  cut  through;  if  so,  it  is  snipped  with  scissors,  in  a  radial  direction, 
in  order  to  let  the  aqueous  escape;  the  membrane  then  often  goes 
back  of  itself.  If  it  does  not  do  so,  then  a  piece  is  excised,  care 
being  taken  to  avoid  traction  on  the  iris,  which  will  otherwise  tend 
to  become  impacted  in  the  narrow  aperture.  As  a  rule,  a  very  small 
and  peripheral  section  of  the  membrane  suffices;  more  rarely  it  is 
necessary  to  make  the  iridectomy  complete.  Elliot  makes  iridect- 
omy in  nearly  all  cases  not  with  the  idea  of  any  therapeutic  benefit 
to  be  derived  from  it,  ])ut  for  the  same  reasons  that  it  is  done  in  extrac- 
tion of  cataract,  merely  to  ])rcvent  the  iris  from  getting  into  the  wound. 
Additional  Poinls  in  Tcchnic. — Colonel  Elliot  visited  Chicago  in 
November  last  making  a  number  of  trephinations  during  his  stay. 
We  were  thus  enabled  to  learn  further  details  concerning  his  methods, 
and  the  knowledge  is  now  imparted  to  those  who  do  not  already 
])0ssess  it.  The  eye  is  held  open  by  a  speculum.  The  patient  is 
made  lo  look  as  far  downward  as  ])ossible  throughout  the  entire 
()|)eralion.  A  fold  of  conjunctiNa,  exactly  in  the  vertical  meridian, 
and  at  least    10  to    12  mm.  from  the  cornea,  is  grasped  with    the 


ELLIOT  S    TREPHIXATIONT 


645 


forceps,  and  here  is  formed  the  apex  of  the  llaj).  'I'he  incisions  that 
form  the  hiteral  borders  of  the  llaj)  do  not,  at  any  point,  approach 
nearer  than  within  4  mm.  of  the  h'mbus.  The  dissection  of  the  (lap 
is  comprised  within  the  area  enclosed  by  the  semicircular  dotted 
line  (Fig.  347).  'J'he  two  bridges  of  conjunctiva  and  episcleral 
tissue,  a  and  b,  are  intentionally  left  undisturbed  in  order  that,  by 
their  elasticity,  they  will  draw  back,  and  hold  to  its  original  position, 
the  conjunctival  flap  after  the  operation  is  completed,  thus  rendering 
a  suture  unnecessary.  With  the  straight,  sharp  ])ointed  scissors  the 
dissection  is  carried  to  the  lim- 
bus,  wlien  the  llaj)  is  turned 
down  o\-er  the  cornea,  where  it  is 
held  smoothly  applied  by  a  wet 
cotton  swab  in  the  hand  of  an 
assistant.  After  this  the  flap  is 
not  grasped  with  forceps,  nor 
any  decided  traction  made  upon^ 
it  lest  it  be  torn  at  the  limbus. 


Elliot's  operation. 


The  dissection  is  now  extended 
to  the  cornea  itself,  s])litting  the 
anterior  layers  from  the  sub- 
stantia propria,  the  flap  being 
meanwhile  gently  worked  down- 
ward by  the  wet  cotton  swab. 
This  part  of  the  dissection  is 
accomplished  with  the  points  of 
the  closed  scissors,  held  verti- 
cally, and  by  careful  to  and  fro 

movements.  It  is  essential  to  precision  that  the  field  be  kept  free  from 
blood.  This  the  assistant  does,  with  his  other  hand,  with  the  aid  of 
cotton  fwabs  wound  on  wooden  toothjjicks.  As  soon  as  a  segment  of 
cornea  measuring  1.5  mm.  in  width  a])pears  above  the  turned  down 
flap  the  dissection  is  stopped,  and  the  trephine  is  applied.  This  is  done 
in  such  a  manner  as  to  cause  the  excised  disc  to  be  composed  some- 
what more  largely  of  corneal  than  of  scleral  tissue.  In  starting  the 
trephine  extreme  caution  is  required  to  avoid  button-holing  the  flaj). 
The  top  of  the  trephine  is  held  between  thumb  and  index,  and  the 
cutting  aft'ected  by  rather  (juick  ])ack  and  forth  twists  of  the  instru- 
ment. As  l)efore  stated,  the  trephine  is  ti])pe(l  slightly  forward,  to 
insure  comjjlete  section  of  the  corneal  portion  of  the  disc,  while  leav- 


646  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

ing  it  attached  by  a  thin  bridge  at  the  scleral  side.  The  grinding  by 
which  the  bit  is  kept  sharp  is  done  upon  the  inside  of  the  tube,  hence, 
having  begun  the  cut,  the  instrument  is  easily  replaced  after  removals 
for  inspection  as  to  progress,  etc.  When  the  corneal  portion  is  well 
cut  through  the  trephine  is  suddenly  withdrawn  to  induce  a  gush  of 
aqueous  that  will  have  a  tendency  to  wash  the  iris  into  the  opening. 
The  speculum  is  now  held  up,  free  of  the  globe,  by  the  assistant, 
while,  by  means  of  forceps,  whose  blades  are  curved  downward, 
the  free  edge  of  the  disc  and  the  protruding  fold  of  iris  are 
seized  (both  in  one  bite  if  practicable)  and  cut  off  with  the  scis- 
sors. Leaving  the  disc  attached  at  the  scleral  side  affords  a  handle, 
as  it  were,  when  held  by  the  forceps,  whereby  the  operator  has  the 
globe  under  perfect  control  during  the  dual  excision,  and  he  need 
have  no  fear  of  a  sudden  rotation  of  that  organ.  A  stream  of  warm 
normal  salt  solution,  from  the  McKeown  irrigaor,  is  now  directed 
into  the  circular  opening,  and  the  iris  washedback  into  place.  There 
is  no  further  instrumentation  through  the  opening  if  it  can  possibly 
be  avoided.  However,  if  the  iris  does  not  present  itself  at  the  open- 
ing upon  completion  of  the  section  it  is  grasped  with  the  iris  forceps, 
withdrawn,  and  excised.  If  vitreous  or  shreds  of  iris  appear  in  the 
hole,  no  attempt  is  made  to  remove  them.  The  iris  having  been 
reposited  the  conjunctival  flap  is  turned  up  and  arranged  in  place, 
but  not  sutured.  The  speculum  is  removed,  both  eyes  are  bandaged, 
the  patient  sent  to  bed  and  instructed  to  keep  very  quiet  for  at  least 
six  hours,  after  which  he  may  be  allowed  greater  freedom  of  move- 
ment. The  eye  is  dressed  on  the  following  day  when,  if  all  has  gone 
well,  the  unoperated  eye  is  left  unbandaged.  After  forty-eight  hours 
the  patient  is  permitted  to  sit  in  a  chair.  At  the  end  of  twenty-four 
hours,  if,  upon  palpation,  the  eye  should  seem  rather  tense — not 
soft — it  is  an  indication  that  there  is  an  obstruction  in  the  scleral 
opening,  and  an  examination  is  made  with  the  ophthalmoscopic 
mirror.  If  the  iris  blocks  the  opening  the  latter  will  appear  dark, 
and  the  conjunctival  flap  should  be  turned  down  and  the  offending 
membrane  at  once  abscised.  If  lens  or  vitreous  causes  the  occlusion 
the  opening  will  show  a  light  reflex,  and,  in  this  case,  the  parts 
involved  are  left  undisturbed. 

The  rather  startling  complication  of  allowing  the  excised  disc  to 
drop  into  the  anterior  chamber  has  been  mentioned  as  having 
happened  to  several  of  the  operators.  I  cannot  believe  that  this 
foreign  body  would  ])rove  innocuous,  and  am  of  ()])ini()n  that  every 


BEARD  S    TREPHINE 


647 


effort  should  be  made  to  ])revcnt  the  accident.  I  have  seen  a  bit  of 
iris  abandoned  in  the  anterior  chamber  cause  so  much  ocuhir  dis- 
turbance than  an  operation  had  to  be  performed  for  its  removal. 
This  falling  within  of  the  disc  would  be  effectually  prevented  by  the 
use  of  such  a  trephine  as  the  ingenious  one  devised  by  Vorhoeff  {The 
Ophthalmoscope,  March,  tqto),  of  Boston,  which  is  provided  with 
a  disc  that  serves  as  a  base  upon  which  the  trephine  cuts,  and  at  the 
same  time  to  hold  the  piece,  or,  rather,  pieces,  cut  out.  Its  em- 
ployment, however,  necessitates  the  making  of  an  incision  through 
which  to  insert  the  disc,  and  it  must  be  an  abrupt  incision — not  the 
long,  slant,  classic  one.  Young,  of  New  York  {Oph.  Record,  Sept., 
1910),  after  making  the  conjunctival  flap,  puts  a  small  loop  of  thread, 
bv  means  of  a  tinv  curved  needle,  through  the  center  of  the  part  to 


Fig.  348. — Beard's  trephine. 

be  excised,  and  passes  the  two  ends  of  thread  up  through  the  trephine, 
as  a  handle  by  which  to  mainpulate  the  disc  and  to  favor  the  progress 
of  the  cutting. 

BearcVs  Trephine.— On  reading  of  Young's  thread  device,  I  was 
greatly  impressed  with  the  desirability  of  a  mechanical  attachment 
for  a  trephine  that  would  serve  to  steady  the  instrument  in  beginning 
the  sclerectomy,  and  also  prevent  the  excised  disc  from  falling  into 
the  chamber.  Shortly  afterward  I  read  a  paper  on  "The  Surgical 
Treatment  of  Glaucoma"  before  the  Chicago  Ophthalmological 
Society,  in  which  I  suggested  a  central  shaft,  provided  at  its  lower 
extremity  with  a  screw,  or  a  barbed  dart,  or  spear,  for  insertion  at 
the  center  of  the  proposed  excision.  This  idea  soon  took  tangible 
form  in  the  trephine  shown  in  Fig.  348,  which  was  exhibited  at  the 
meeting  of  the  American  Medical  Association  (Ophthalmic  Section), 
and  at  that  of  The  American  Ophthalmological  Society,  both  taking 
place  at  Atlantic  City,  in  June,  1912.  A  description  of  the  instru- 
ment and  its  manner  of  application,  however,  has  never  before 
appeared  in  print.     It  consists  of  two  members,  an  outer  hollow 


648 


THE    NEWER    OPERATIONS    FOR    GLAUCOMA 


tube,  and  an  inner  shaft,  or  axis.  The  shaft  has  a  collar  near  the 
lower  end  which  fits  nicely  in  the  tube,  to  avoid  wabbling.  Its  upper 
end  is  composed  of  a  milled  knob,  by  which  the  shaft  is  turned,  and 
its  lower  one,  of  a  minute  screw.  The  portion  of  the  shaft  which 
projects  above  the  tube  is  fitted  with  a  sliding  nut  that  acts  as  a 
gauge  of  depth  in  the  cutting.  This  may,  with  propriety,  be  left  off 
if  the  surgeon  so  chooses.     The  working  end  of  the  tube  is  so 


Fig.  349. — The  use  of  the  Beard  corneal  trephine. 


constructed  as  to  allow  the  bits,  of  which  there  are  two  sizes,  to  be 
easily  changed  and  adjusted  for  depth.  One  bit  has  a  diameter  of 
1.5  mm.,  the  other  of  2  mm.  The  mode  of  operation  is  quite  simple. 
The  site  of  the  trephination  having  been  prepared,  as  described  on 
page  64.9,  the  shaft  is  pushed  downward  so  as  to  expose  the  screw;  the 
point  of  the  latter  is  set  at  the  exact  spot  intended  as  the  center  of  the 
excision,  when  the  knob  at  the  top  is  turned  to  the  right  until  the 
screw  is  forced  into  the  sclera  u])  to  the  shoulder,  \\\[h  which  it  is  su])- 


CONJUNCTIVAL    FLAP    FOR    TKEPHIXATK  )\  649 


C  I> 

Fig.  350.— Author's  method  of  making  the  conjunctival  Ihip  for  trephination. 
That  depicted  at  B  is  no  longer  employed,  the  section  being  completed  with  the  bis- 
toury, as  shown  at  A. 


650  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

plied,  indicating  that  the  screw  has  penetrated  to  a  depth  of  a  trifle 
more  than  a  millimeter.  The  bit  is  now  slid  down,  in  contact  with 
the  globe,  and  the  sliding  nut,  at  the  top,  in  contact  with  the  upper 
end  of  the  tube,  when  the  cutting  begins.  This  is  accomplished  by 
turning  the  tube  with  thumb  and  finger  applied  to  the  middle,  or 
smaller  part  of  the  tube,  and  always  to  the  left.  This  last  precaution  is 
taken  to  insure  a  hold  upon  the  disc  when  the  sclera  (or  cornea)  is 
cut  through.  Were  the  tube  turned  to  the  right,  the  disc  would  tend 
to  unscrew  itself  when  loosened.  Obviously,  the  screw  having  been 
fixed  with  precision,  there  can  be  no  wavering  of  the  bit  before  its 
bite  is  well  started.  Besides,  it  helps  to  steady  the  eye,  doing  away 
with  the  need  of  forceps  fixation;  although  there  is  no  objection  to  the 
latter,  provided  it  is  entrusted  to  a  trained  hand  (Fig.  349).  The 
circular  incision  having  been  completed,  save  for  a  thin  bridge  at  the 
scleral  side,  the  trephine  is  lifted,  and  the  central  shaft,  with  its 
screw  still  fast,  is  used  as  a  handle  by  which  to  steady  the  globe 
and  to  manipulate  the  piece  of  sclera  while  finishing  its  excision  with 
the  scissors.  The  barbed  arrow  idea  was  abandoned  because  it 
would  be  too  difficult  of  extraction  in  an  emergency.  But  would 
the  emergency  arise?  If  not,  it  would  be  superior,  perhaps,  to  the 
screw. 

Ophthalmic  surgeons  have  been  rather  prolific  of  late  in  the 
creation  of  original  models  in  trephines,  all  of  which  seem  to  work 
satisfactorily.  Fox  has  adapted  the  von  Hippie  instrument  to 
sclerectomy.  Young,  of  New  York,  and  Pusey,  of  Chicago,  have 
each  furnished  one,  not  to  mention  others. 

Formation  of  the  Conjunctival  Flap. — The  British  surgeons 
hinge  theirs  in  the  corneal  tissue.  Webster  Fox's  hinge  is  at  one 
side,  and  in  reuniting  the  flap  he  draws  it  down  obliquely  over  the 
corneal  margin,  and  fixes  it  with  a  single  suture.  After  trying 
several  methods,  I  have  finally  adopted  that  illustrated  in  Fig.  350. 
The  flap  is  outlined  laterally  by  two  meridional  incisions,  made  with 
forceps  and  scissors  (Fig.  350,  A).  It  is  tunneled  under  near  the 
cornea  with  curved,  blunt-pointed  scissors,  when  a  cm-ved  iris  spatula 
is  put  through  and,  by  prying  and  riving,  the  conjunctiva  is  loosened 
clean  u]j  to  its  more  solid  attachment  at  the  limbus.  Now  a  curved, 
blunt  l)istoury,  or  Weber's  probe  pointed,  curved  lacrimal  knife 
(Plate  I,  Nos.  6  and  9)  is  put  through  the  tunnel  beneath  the  conjunc- 
tiva and,  by  a  sawing  movement,  not  only  is  the  end  of  the  flap  set 
free,  but,  at  the  same  time,  a  lunulate  piece,  comi)osed  of  the  antrrior 


co^7UNCTrvAL  flap  for  trepiiixatiox  651 

lavLi-s,  is  shaved  from  the  cornea  (Fig.  350,  B).  The  scale  of 
corneal  tissue  is  cut  off  the  end  of  the  llap,  and  a  suture  is  passed 
from  above  downward  through  each  of  its  free  corners.  Having 
proceeded  in  the  manner  described,  one  has  a  clear  field  for  the  trejjh- 
ination  (Fig.  350,  C),  the  completion  of  which  is  followed  by  passing 
one  of  the  needles  through  the  attached  conjunctiva  at  either  side, 
sufficiently  far  down  to  cause  the  flap  to  fully  cover  the  scleral  opening 
when  the  sutiu-es  are  tied  (Fig.  350,  D).  It  is  well  to  pull  the  flap 
over  before  the  final  passage  of  the  thread  to  see  how  it  fits. 

The  making  of  the  conjunctival  flap  is  the  longest  and  most  difli- 
cult  step  in  the  Elliot  operation.  To  the  average  surgeon  it  is  no 
easy  matter  to  split  the  cornea  at  the  precise  depth,  and  throughout 
a  sufficient  area,  without  button-holing  the  flap  or  leaving  it  in  the 
way  of  the  trephine.  Especially  is  this  true  of  those  cases  in  which 
scar  tissue  is  present  as  the  result  of  a  previous  iridectomy,  or  an 
extraction.  If  said  button-holing  takes  place  it  is  most  likely  to  be 
at  the  site  chosen  for  the  trephination,  and  this  brings  about  a  most 
awkward  situation.  If  the  flap  is  formed  after  the  manner  just 
described,  it  is  quickly  and  easily  done,  a  clear  field  is  afforded  for 
the  trephining,  and  the  lunulate  raw  siurface  on  the  cornea  furnishes 
ideal  ground  for  the  immediate  adherence  of  the  flap.  Thus  the 
scleral  opening  is  as  effectually  covered  as  if  the  flap  had  been  formed 
with  its  free  end  backward,  and  the  objection  urged  to  this  form  of 
flap— that  it  would  permit  the  growing  of  epithelium  into  the  opening 
— is  done  away  with. 

:;.  Operations  to  Establish  Communication  between  the 
Anterior  Chamber  and  the  Peri-choroidal  Spaces.— Of  these 
one  need  mention  only  that  of  Heine,  or  cyclodialysis,  which  is 
described  on  page  422.  According  to  many  observations,  and 
experiments  upon  animals,  the  hypothesis  of  creating  a  permanent 
detachment  of  the  choroid  to  effect  a  communication  between  the 
anterior  chamber  and  the  suprachoroidal  space,  upon  which  the 
operation  is  based,  has  not  been  confirmed.  Clinical  data  show  that 
favorable  results  of  cyclodialysis  have  been  obtained  in  relatively 
few  cases;  that  they  are  seldom  lasting,  and  that  complications  are, 
perhaps,  more  frequent  after  this  than  after  most  of  the  other  anti- 
glaucomatous  operations.  Among  the  complications  are  implan- 
tation cysts  and  choroidal  hemorrhage.  It  would  seem  to  be 
admissible  chietly  in  blind  eyes,  or  as  a  preparatory  measure,  where 
the  hypertonicity   is  excessive,   the  anterior  chamber  obliterated, 


652  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

and  there  exist  adherences  of  iris,  in  order  to  get  transitory  diminu- 
tion of  the  tension  with  an  appreciable  depth  of  the  anterior  chamber, 
to  faciUtate  further  interference  by  another  method. 

4.  Non-perforating  Sclerectomy. — This  form  of  surgery  for 
chronic  glaucoma  stands  in  a  class  by  itself.  Its  chief  exponent  is 
Dr.  Bettremieux,  of  Roubaix,  France,  although  some  of  Lagrange's 
o])erations  have  been  of  a  similar  kind.  Bettremieux  declares 
that  for  sclerectomy  to  be  eiTecti\e  it  need  not  be  perforating.  It 
consists  in  substituting  for  the  incision  the  excision  of  a  strip  of  the 
pericorneal  sclera  without  disturbing  the  deeper  tunics  of  the  globe. 
It  is  claimed  for  the  measure  that  it  meets  two  most  important 
indications.  First,  it  obviates  the  leaving  of  that  dense  cicatrization 
which  often  after  incision  is  less  permeable  than  was  the  original 
sclera.  Second,  the  result  is  a  thinning  of  the  sclera  about  the  irido- 
corneal angle,  a  thinning  absolutely  free  from  any  incarceration  or 
adhesion  of  the  underlying  ocular  structures.  The  only  anti- 
glaucomatous  operation  which,  as  regards  harmlessness,  can  be 
compared  to  this  is  sclerotomy,  and  we  know  how  uncertain  is  the 
latter  of  yielding  permanent  results. 

Bettremieux' s  Theory  of  Glaucoma. — "Glaucoma  is  essentially  a 
disturbance  of  the  blood  circulation  of  the  eye."  Sclerectomy 
favors  the  tlow  of  venous  blood  out  of  the  eye  in  the  pericorneal 
region.  He  does  not  believe  that  scleral  incisions  and  excisions  act 
in  glaucoma  by  that  scleral  incisions  and  excisions  act  in  glaucoma 
by  facilitating  the  exit  of  aqueous  through  a  filtration,  or  a  fistulous 
cicatrix,  but  that  they  combat  the  blood  stasis  by  creating  anasto- 
moses between  the  deep  vessels  of  the  pericorneal  region  and  the 
conjunctival  and  subconjunctival  vessels.  Simple  paracentesis  of 
the  anterior  chamber,  he  says,  sometimes  paUiates  the  glaucomatous 
symptoms  by  the  fact  that  it  releases  the  anterior  blood  channels  of 
the  eye. 

Bettremieux's  operation  consists  in  an  excision  of  the  greater 
thickness  of  the  sclera  from  a  small  area  at  the  base  of  the  cornea, 
but  respecting,  or  leaving,  the  most  internal  fibers.  Aside  from  the 
chances  it  offers  for  the  anastomoses  just  referred  to,  the  author  of 
the  measure  contends  that  the  possibilities  thus  afforded  for  a  filtra- 
tion area,  at  least,  equal  those  of  operations  that  have  for  object  the 
making  of  a  fistulous  tract,  and  those  for  contingencies  and  dangers 
almost  nil.  By  way  of  illustration  he  says:  "Suppose  one  wished 
to  make  a  fihration  area  in   the  side  of  an  earthen  vessel,  would   it 


I?F,TTREMIKrX  S    METIIOD 


653 


]i()l  be  ])cltL'r  to  scrajjc  away  the  material  until  the  wall  was  suni- 
cienlly  thin  to  allow  of  slight  seepage,  than  to  make  an  actual  hole?" 
Amon.u;  the  other  a(lvanta,<i;es  claimed  for  the  oj)eration  is  that  the 


thinned  sclera  remains  absolutely  free  from  any  invoKement  of  the 
structures  within  the  globe. 

Ma>ificr  of  Proceed  ill  s^. — The  operati\e  field  may  be  either  above 


654  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

or  below.  Bettremieux  usually  chooses  the  latter  location.  Cocain 
anesthesia  (by  instillation).  Adrenalin  is  necessary  after  the 
conjunctival  flap  is  dissected  free,  in  order  that  one  may  see  clearly 
to  make  the  sclerectomy.  The  sclera  adjoining  the  limbus  is  laid 
bare  by  making  a  conjunctival  flap,  free  end  toward  the  limbus, 
and  at  least  12  mm.  in  width  (Fig.  351).  Formerly  a  broad,  curved 
needle  was  passed  deep  into  the  scleral  tissue  at  the  base  of  the 
cornea,  and  left  there,  convexity  downward,  Mobile,  by  means  of  a 
narrow  Graefe  knife,  what  was  included  in  the  concavity  of  the 
needle  was  sliced  out.  At  present  the  sclera  is  picked  up  in  small 
sections,  by  specially  constructed  forceps,  and  the  pieces,  or  shavings, 
excised  with  the  same  knife.  Each  branch  of  the  forceps  is  ter- 
minated by  a  tiny  talon,  or  thorn-shaped  tooth,  set  perpendicular 
to  the  branch,  their  points  directed  one  toward  the  other,  and  almost 
in  contact  when  the  forceps  is  closed.  The  scleral  breach  extends 
for  10  mm.  along  the  corneal  margin,  and  is  about  2  mm.  wide. 

In  fashioning  the  conjunctival  flap  it  is  outlined  laterally  by  two 
meridional  incisions.  The  sclerectomy  finished,  a  suture  is  put  into 
either  corner  of  the  flap,  and  it  is  drawn  up  and  fixed  in  such  a 
manner  as  to  slightly  overlap  the  cornea,  thus  completely  covering 
the  breach. 

On  two  recent  occasions  I  have  made  the  Bettremieux  sclerectomy 
with  a  rather  narrow  Graefe  knife,  (Fig.  352)  removing  the  piece  of 
sclera  in  one  shaving.  In  finishing  the  section  a  very  narrow  line  of 
clear  cornea  may  be  included,  but  this  does  not  matter — in  fact, 
gives  finish  to  the  operation  by  affording  a  fit  surface  for  the 
adherence  of  the  conjunctival  flap.  True,  the  scleral  defect  does 
not  take  the  form  of  a  rectangle,  when  made  in  this  manner,  which 
also  is  of  no  consequence,  so  long  as  the  depth  and  area  of  the 
excision  are  correct. 

If  desired,  the  operation  may  be  combined  with  paracentesis  of 
the  anterior  chamber.  Bettremieux  has  made  as  many  as  three 
such  sclerectomies  in  the  same  eye.  If,  in  the  end,  it  prove  in- 
effective, one  may  still  have  recourse  to  sclerotomy,  perforating 
sclerectomy  or  iridectomy.  Bettremieux  also  performs  this  operation 
in  certain  cases  of  detachment  of  the  retina.  (See  Chapter  on  that 
subject.) 

Fistulous  Tracts  by  Means  of  Silk  Thread. — At  the  meeting  of 
the  Ophthalmological  Society  of  the  United  Kingdom,  March  r4,- 
19 1 2,  a  report  was  made  on  a  new  procedure  by  Mr.  M.  Stephen 


IMPLANTATION    OF    TIIRKAD  655 

Mayou  {The  Ophthalmoscope,  ^Mav,  1912),  The  ()j)fration  is  de- 
signed to  correct  the  fault  common  to  most  o])erations  (k-jjending 
upon  a  filtration  cicatrix,  that  of  the  wound  healing  lirnily,  stopping 
fdtration  through  the  cicatrix  with  resuUing  rise  of  tension. 

The  method  of  procedure  is  as  follows:  After  the  instillation  of 
adrenalin,  cocain,  and  eserin,  a  very  large  and  thick  conjunctival 
flap  is  turned  forward  over  the  cornea  and  carefully  dissected  up  to 
the  limbus.  An  incision,  about  3  mm.  long,  is  made  from  the  outside 
into  the  anterior  chamber,  by  gradually  cutting  through  the  fibers  of 
the  sclerotic  with  the  knife  point,  starting  2  mm.  behind  the  limbus. 

A  piece  of  black  silk  thread,  5  mm.  long,  ha\ing  a  knot  at  one  end, 
is  carefully  sterilized  and  with  a  pair  of  force])S  is  laid  across  the 
incision  in  the  sclera.  With  a  narrow  iris  spatula,  having  a  rounded 
notch  in  the  end,  the  silk  is  tucked  into  the  incision.  As  the  silk 
is  pushed  forward  into  the  anterior  chamber,  the  knot  sticks  in  the 
lips  of  the  wound,  while  the  free  end  passes  forward  into  the  angle 
of  the  anterior  chamber.  The  conjunctival  flap  is  then  replaced  in 
position,  a  stitch  being  inserted  if  necessary.  The  whole  operation 
can  be  performed  without  emptying  the  anterior  chamber,  and  is 
quite  easy  to  execute. 

The  wound  in  the  conjunctiva,  after  forty-eight  hours,  is  usually 
firmly  healed  and  the  subconjunctival  tissue  is  filled  with  fluid.  At 
first  this  usually  extends  beyond  the  area  of  the  conjunctival  flaj), 
but  after  a  time  it  becomes  more  localized.  The  tension  of  the 
eye  is  usually  subnormal  from  four  days  to  a  week,  after  which  time 
it  regains  its  normal  tension.  In  none  of  the  cases  was  there  any 
iritis  or  undue  reaction;  the  only  contretemps  was  in  one  case, 
where  there  was  a  small  prolapse  of  the  iris  at  the  time  of  operation. 
This  was  probably  due  to  the  fact  that  eserin  had  not  been  previously 
instilled,  and  that  the  incision  was  made  rather  larger  than  usual. 
Four  cases  are  reported  as  successfully  operated  by  the  above 
method. 

At  the  same  meeting  a  similar  measure  was  described  by,  and  as 
emanating  from,  ^Mr.  Arthur  Zorab  {The  Ophthalmoscope,  jSIarch, 
1912). 

The  procedure  was  followed  with  success  on  four  eyes:  The 
eye  is  cocainized  and  cleansed  in  the  usual  way,  eserin  being  used  to 
contract  the  pupil.  A  large  flap  of  conjunctiva  is  then  raised  otT  the 
globe,  a  crescentic  attachment  at  the  limbus  being  left.  P""or 
choice,  the  flap  should  be  taken  from  the  up])er  ])art.  which  is  gener- 


656  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

ally  covered  by  the  lid.  The  whole  thickness  of  the  conjunctiva  is 
taken,  and  as  the  limbus  is  neared,  the  conjunctiva  here  being  thin, 
great  care  is  taken  not  to  make  a  "buttonhole."  The  flap  is  then 
reflected  on  to  the  cornea,  and  the  globe  being  steadied  by  fixation 
forceps  at  the  opposite  side  an  incision  is  made  with  a  keratome  into 
the  anterior  chamber. 

The  incision  is  about  3  mm.  long,  and  begins  about  2  mm.  from 
the  corneal  margin.  A  small  piece  of  sterile  silk,  not  more  than  half 
an  inch  long,  is  doubled  on  itself,  the  bend  placed  against  the  lips  of 
the  wound  in  the  sclera,  and  pushed  in  with  the  spatula.  As  soon  as 
the  1)end  can  be  seen  in  the  chamber  the  flap  of  conjunctiva  is  re- 
placed, thus  covering  the  distal  portions  of  the  silk.  Great  care  is 
taken  at  this  stage  to  see  that  the  ends  of  the  silk  are  well  away  from 
the  margin  of  the  conjunctival  flap,  it  sometimes  being  necessary  to 
cut  off  a  small  piece  from  each  end.  The  flap  is  then  stitched  in  a 
couple  of  places  and  the  operation  is  complete. 

The  eye  is  bandaged  for  a  couple  of  days,  but  the  patient  is  up  and 
about  on  the  day  after  the  operation.  There  is  very  free  drainage 
for  the  first  few  days,  the  chamber  being  abolished,  and  the  con- 
junctixa  rendered  very  edematous  by  the  aqueous.  Within  a  week 
the  chamber  is  reestablished,  and  the  conjunctival  condition  improves 
rapidly.  An  appendix  is  added  of  ten  eyes,  four  of  which  were 
operated  by  the  above  method,  and  six  by  similar  procedure. 

Remarks. — Were  I  requested  to  give  a  brief  critical  review  of 
the  procedures  discussed  in  this  chapter,  as  based  upon  personal 
experience  with  most  of  them,  upon  direct  observation  of  the  work 
of  my  immediate  colleagues,  upon  published  reports,  and  upon  mere 
theoretical  deductions,  it  would  be  undertaken  with  considerable 
misgiving.  A  few  points,  however,  seem  to  stand  clearly  forth. 
It  is  certain,  for  instance,  that  operations  for  chronic,"  simple  glau- 
coma that  concern  principally  the  iris  are  the  least  to  be  relied  upon : 
not  that  they  do  not  bring  a  high  percentage  of  favorable  results  in 
certain  selected  cases.  The  efficacy  of  iridectomy  in  the  early 
stages,  with  rapid  formation  of  the  glaucomatous  excavation  at  the 
papilla,  is  undeniable.  But  this  limits  its  application  to  relatively 
few  cases.  In  the  e\ent  of  a  relapse  it  precludes  the  use  of  myotics, 
and  could,  even  in  these  few  cases,  be  well  supplanted  by  one  of  the 
simpler  measures.  As  concerns  the  operation  of  iridenkleisis  or 
iridotasis,  whik'  it,  too,  is  often  effective  in  ])ermanently  relieving 
hypertension,   the  condition   it  Ijrings  about  is  a   treacherous  one, 


1 1 

).     'Vhv  (■()nii)lirali(jns  and 

th 

(■    iris    arr    responsible    are 

y 

i(|(lin,L,f  lo  ihrm.     It  seems 

\v 

til  iridcnkleises  came,  in  a 

//d{ 

on   of   its  drawbacks,   and 

Ri:\ii;\\    OF  MirriioDS  657 

whose  e\-ils  ha\c  ])ccn  already  allude 
disasters  for  which  inxoKcnieiit  of 
numerous  enou,L,di  without  our  wilful 
that  every  sursi;e<)n  who  e\er  took  uji 
comparatixc'ly  short  time,  to  a  realiz; 
ceased  to  achocate  it. 

The  chief  objections  to  the  perforatinjj;  sclerectomies — and  these, 
strictly  speaking,  include  trephination  of  the  sclera — is  that  they 
are  rather  too  formidable,  and  provocative  of  complications,  to  be 
generally  ap])licable  in  simple  glaucoma.  Measures  like  those 
accredited  to  Lagrange  and  Holth  are,  of  necessity,  restricted  to 
glaucomatous  eves  whose  anterior  chamber  is  not  wholly  lacking, 
and  whose  hv])ertension  is  not  extreme.  Vet,  it  is  only  in  the  hands 
of  the  more  skillful  surgeons  that  they  yield  anything  like  their  full 
quota  of  success.  There  are  always  injury  to  the  zonule  of  Zinn, 
loss  of  vitreous,  and  iris  complications  to  be  feared.  Hut  little  less 
formidable  are  the  different  methods  of  trephining,  especially  as 
regards  their  results  in  the  hands  of  the  average  ophthalmic  surgeon. 
Notwithstanding  the  soundness  of  their  basic  principle,  their  most 
useful  sphere  seems  to  be  contmed  to  cases  characterized  by  high 
tension,  with  total  obliteration  of  the  anterior  chamber,  and  to  those 
wherein  other  measures  have  been  fully  tried  and  found  without 
avail.  We  are  becoming  more  and  more  aware  of  the  fact  that  the 
operation  of  Elliot  is  not  the  innocuous  measure  that  it  was  at  first 
believed  to  be.  Axenfeld  has  observed  that  it  is  apt  to  be  followed  by 
a  mild  iritis,  and  considers  it  more  hazardous  than  Lagrange's  opera- 
tion. Axenfeld  also  warns  us  not  to  be  misled  by  the  elevation,  or 
cushion,  which  usually  appears  over  the  site  of  the  scleral  excision 
after  trephining.  Its  presence  is  not  necessarily  an  indication  that 
filtration  is  going  on  there.  On  the  contrary,  the  sclera  may  have 
become  so  dense  at  this  point  as  to  be  absolutely  impervious  to  any 
kind  of  transudation.  Nor  does  the  absence  of  the  elevation  prove 
that  the  trepanation  has  been  fruitless.  There  may  be  no  visible 
evidences  of  a  filtration  cicatrix,  yet  the  result  of  the  operation  be  all 
that  could  be  desired.  This  is  one  of  the  reasons  given  by  Axenfeld 
for  believing  that  the  accompanying  iridectomy  is  of  therapeutic 
value.  Indeed,  others  will  take  issue  with  Colonel  Elliot  relative  to 
the  effect  of  the  iridectomy  in  this  connection.  It  has  been  demon- 
strated that  the  vast  majority  of  trephinings  necessitate  also  some 
form  of  iridectomy.  Reports  of  late  infection  after  trephining 
4^ 


658  THE    NEWER    OPERATIONS    FOR    GLAUCOMA 

ha\c  already  become  numerous;  and  it  is  precisely  in  those  cases 
with  the  ideal  cicatrix  that  this  is  most  likely  to  occur.  Besides, 
the  benefit  is  often  but  transitory.  These  observations  relative 
to  the  indications  for  trephination,  be  it  understood,  have  refer- 
ence mainly  to  personal  acquaintance  with  the  measure,  and  must  not 
be  construed  as  reflecting  upon  the  statements  of  those  who  give  to  it 
a  wider  range  of  application.  When  we  consider  the  large  percentage 
of  eyes  that  come  within  the  "said  sphere  of  usefulness,"  the  latter, 
it  will  be  seen,  is  by  no  means  insignificant.  The  operation  is,  with- 
out doubt,  a  truly  valuable  acquisition  to  ophthalmic  surgery. 

When  it  is  a  question  of  choosing  the  manner  of  intervening 
surgically  in  simple  glaucoma,  when  there  is  still  present  a  useful 
degree  of  vision,  and  the  field  is  not  too  greatly  contracted,  my 
individual  preference  is  for  some  form  of  anterior  sclerotomy. 
An  incision  with  the  lance  keratome,  made  just  as  is  that  univer- 
sally adopted  for  inflammatory  glaucoma,  though  hardly  so  ex- 
tensive, wdll  often  suffice,  especially  when  followed  by  pression 
massage.  And  it  may,  with  impunity,  be  repeated  over  and  over, 
if  occasion  arises.  A  more  finished  and  a  safer  operation  results 
if  the  dissection  of  a  conjunctival  flap,  hinging  at  the  limbus,  is 
made  a  preliminary  to  the  incision,  as  described  early  in  this  chapter. 
Here,  of  course,  great  prudence  is  necessary,  in  the  final  suturing  of 
the  flap,  to  avoid  an  accident  due  to  squeezing  on  the  part  of  the 
patient.  The  author's  modification  of  the  De  Wecker  sclerotomy 
has  the  great  advantage  of  being  accomplished  entirely  beneath  the 
conjunctiva.  Should  a  stubborn  prolapse  of  the  iris  occur  it  is  not 
too  late  to  dissect  up  the  flap  in  order  the  better  to  deal  with  the 
extrusion.  With  the  sphincter  artificially  contracted,  and  by  con- 
trolling the  outflow  of  aqueous,  then  exercising  proper  care  in  the 
after-treatment,  iris  complications  are  little  to  be  apprehended. 
The  last  comprehends  the  use  of  a  binocular  bandage,  surmounted 
by  a  protective  mask. 

Or  one  may,  with  equal  assurance,  have  recourse  to  the  method 
of  Herbert,  or  to  that  of  Bettremieux.  The  last  is  particularly 
to  be  recommended  as  a  tentative  measure,  when  the  somewhat 
more  radical  anterior  sclerotomy,  with  or  without  massage,  can  be 
held  in  reserve  against  the  return  of  glaucomatous  symptoms. 

If  there  is  any  truth  in  the  theory,  originally  advanced  by  Stellwag, 
that  an  abnormally  rigid  sclera  is  sometimes  the  cause  of  hyper- 
tension of  the  globe,  the  grill-like  sclerotomy  of  Wicherkiewicz  is 


CHOICE    OF    METHOD  659 

well  concci\c(l,  and  worthy  of  ccjiisickTation  Ix'cause  of  its  sinij)licity 
and  harmlessness.  Its  author  indicates  the  maiiiuT  of  selecting 
cases  to  which  the  measure  is  suited. 

Against  the  introduction  of  threads  of  silk,  as  proposed  by  Mcssers 
Mayou  and  Zorab,  the  trite  objection  to  the  presence  of  a  foreign 
body  is  at  once  suggested.  Granting  that,  in  this  instance,  the 
objection  is  invalid,  the  question  arises — will  not  the  thread  become 
so  firmly  incorporated  with  the  siu-rounding  tissues  as  to  render  it 
useless  as  a  means  of  drainage  ? 


CHAPTER  XIII. 
OPERATIONS  FOR  DETACHMENT  OF  THE  RETINA. 

The  ophthalmic  surgeon  is  justly  proud  of  his  achievements,  but 
in  the  presence  of  this  dread  affection  he  grows  pessimistic — too 
much  so  perhaps.  There  may  be  a  great  deal  of  truth  in  Deutsch- 
mann's  remark  that  /'Suppose  one  has  convinced  himself,  even  after 
exhausting  the  ordinary  measures,  that  they  are  generally  useless,  he 
is  not  justified  in  idly  folding  his  hands  in  his  lap,  and  trusting  to 
the  slender  chance  of  a  spontaneous  cure."  The  discouraging 
responses  received  by  \'ail  from  his  recent,  widespread  interrogatory 
among  oculists,  relative  to  their  experience  with  retinal  detach- 
ment, may  not  all  have  come  from  men  who  had  resorted  to  those 
surgical  procedures,  of  attested  merit,  which  have  been  devised  for 
the  trouble.  True,  it  is  an  affection  w^hose  etiology  is,  as  yet,  de- 
cidedly indefinite.  As  Dufour  says  "It  is  not  a  morbid  entity,  but 
an  anatomic  (mechanical)  accident,  that  complicates  diverse 
intraocular  diseases."  And  further,  that,  in  our  treatment  of  it, 
we  should  bear  in  mind  that  "there  is  no  disease  bearing  the  name 
detachment  of  the  retinal     It  is  a  condition  that  is  thus  named. 

It  is  traumatic  or  non-traumatic.  The  non-traumatic  is  usually 
referred  to  by  the  rather  ambiguous  terms  idiopathic  and  spontaneous, 
and,  in  general  discussions  of  the  subject,  is  the  kind  referred  to. 
The  traumatic  variety  comprises  from  15  to  18  per  cent,  of  all  de- 
tachments, and  its  surgical  treatment  is  not  essectially  different 
from  that  of  the  idiopathic.  Detachment  is  more  common  in  males 
between  the  ages  of  forty-five  and  sixty.  It  is  bilateral  in  a  large 
percentage  of  non-traumatic  cases — variously  estimated  at  from  8 
to  7,2,  per  cent. ;  is  complicated  by  some  form  of  cataract  in  45  per 
cent,  and  is  associated  with  myopia  in  considerably  more  than  50 
])er  cent.  Myopia  does  not,  however,  bear  a  causal  relation  any 
more  than  does  cataract.  It  is  another  condition,  but  one  which 
predisposes  to  detachment.  The  surgical  measures  de\ised  for 
detachment  may  be  divided  into  four  groups,  according  to  their 
avowed  object: 

()6o 


DEUTSCHMAXN  S    OPERATIONS  66 1 

1.  The  evacuation  of  the  sub-choroidal  (or  retro  retinal)  h'(|ui(l. 
These  include: 

(/.  Simple  scleral  and  choroidal  f>unctio)i.      (Ware,  Sichel.  Killel.) 

b.  Aspiration,      ((ialezowski,  Dc  Wecker.) 

c.  Iridectomy.      (Fano,  Dransart.) 

2.  The  creation  of  adhesions  between  retina  and  chc^roid  or  sclera. 
a.  Injection  of  iodin.  or  its  compounds.      (Sch(iler,  Abadie.) 

h.   Thermocautery.      {ChwdW  Doereau,  I)e  Wecker,  Dor.) 

c.  Preretinal  electrolysis.      (Terson.) 

d.  Retinoscleral  suture.     (Meyer,  Galezowski.) 

,:;.  Severance  of  bands,  or  points  of  adhesion,  between  vitreous  and 
retina. 

a.  Discission.      (\\)n  (}raefe,  C.  S.  Bull.j 

h.  Intravitreous  electrolysis.      (Abadie.) 

4.  Shrinking  the  sclera  onto  the  already  shrunken  vitreous 
(Mueller),  or  some  combination  of  these  measures.  Deutschmann's 
operations,  for  example,  are  combinations  of  several  of  the  above. 
Burning  with  the  galvano-cautery  is  sometimes  carried  to  perfora- 
tion of  the  sclera,  etc.  By  subconjunctival,  or  sub-tenonian  injections 
one  looks  to  osmosis  for  the  results. 

To  attempt  a  description  of  more  than  a  few  of  the  many  methods 
by  which  these  different  objects  are  sought,  would  be  needless,  and 
prove  tedious  to  the  reader;  therefore,  only  a  limited  number  of  those 
most  widely  commended  will  be  given. 

I.  (a)  Simple  scleral  puncture,  or  paracentesis,  is  not  a  formidable 
procedure,  and  is  ])robably  as  effected  as  most.  It  consists  in 
merely  fixing  the  globe  by  grasping  the  conjunctiva  at  the  infero- 
nasal  limbus,  rotating  it  u])ward  and  outward,  and  making  a 
meridional  puncture,  with  a  two-edged  (original  Graefe)  knife, 
between  the  tendons  of  the  internal  and  the  inferior  recti— nearer 
the  latter.  Having  pierced  the  choroid,  the  knife  is  rotated  so  as  to 
pry  open  the  wound  and  drain  the  fluid  beneath  the  detachment^ 
the  situation  of  the  latter  being,  of  course,  downward.  .A.s  the 
operator  is  about  to  make  the  puncture,  an  assistant  pulls  the  con- 
junctiva to  one  side  with  tcjothed  forceps,  so  that  the  outer  wound 
will  not  coincide  with  that  in  the  sclera.  This  location  of  the 
puncture  is  the  one  least  likely  to  implicate  the  larger  choroidal  and 
retinal  vessels,  and  is  at  a  safe  distance  from  the  niacuhi.  Both, 
eyes  are  bandaged,  the  patient  kept  in  bed,  and  such  other  subsidiary 
measures  adopted  as  seem  warranted. 


662  OPERATIONS    FOR    DETACHMENT    OF    THE    RETINA 

b.  Aspiration  as  a  single  measure  is  no  longer  resorted  to. 

c.  Iridectomy  is  described  elsewhere.  It  should  be  of  the  kind 
made  for  glaucoma. 

2.  From  this  group  I  would  select  only  b.  Thermo-  (galvano-) 
cautery,  without  perforation  of  the  two  outer  tunics  of  the  globe. 
De  Wecker  laid  bare,  and  incised  the  sclera,  then  burned  through  to 
the  fluid,  by  way  of  the  cut,  while  others  first  perforated  with  the 
cautery,  then  slit  the  retina  through  the  opening.  The  more 
approved  method,  and  one  that  has  proven  efficacious,  and  less 
provocative  of  injury,  is  multiple  punctate  cauterization  of  the  outer 
substance  of  the  sclera,  over  the  site  of  the  detachment.  The 
cauterization  may  be  carried  well  back  toward  the  equator,  as  there 
is  no  danger  to  important  vessels  unless  it  extends  to  the  vorticose 
trunks.  The  customary  mode  of  proceeding  is  to  expose  the  sclera, 
over  the  seat  of  the  lesion,  by  freely  incising  conjunctiva  and  fibrous 
capsule,  retract  the  cut  edges  with  Steveses'  squint-hooks,  and  make 
from  three  to  six  applications  of  a  small  spherical,  or  loop  cautery 
point,  laid  on  cold,  and  heated  to  cherry  redness  in  situ.  The  mem- 
branes are  sutured,  and  the  eyes  bandaged.  The  measure  not  only 
tends  to  set  up  adhesive  inflammation  between  the  bulbar  tunics,  but 
also,  according  to  Elsching,  to  shrink  the  sclera  upon  the  ocular 
contents,  both  of  which  are  curative  of  the  malady  in  question. 

3.  Of  this  class  mention  need  be  made  only  of  the  operation  of 
discission  of  restraining  vitreous  bands,  as  practised  rather  ex- 
tensively, and  with  a  fair  degree  of  success,  by  the  late  Charles 
Stedman  Bull.  After  studying,  with  the  ophthalmoscope,  the  di- 
rection of  the  principal  bands  he  pierced  the  vitreous  chamber  with 
a  small  narrow  knife,  at  the  point,  and  in  the  manner,  most  favor- 
able for  the  purpose,  and  severed  the  bands  athwart.  The  oph- 
thalmoscope has  been  successfully  employed  to  guide  the  manipula- 
tion of  the  knife.  The  measure  is  contraindicated  when  the  eye  is 
inflamed,  or  when  the  vitreous  bands  have  become  vascularized. 

4.  The  formidable  sclerectomy  of  L.  Mueller  ^is  described  on 
page  427. 

Elschnig's  Modification  of  Mueller^ s  Procedure. — ^A  friend  of  the 
writer  having  just  returned  from  Europe,  where  he  visited  Prag  and 
Professor  Elschnig's  clinic,  described  to  him  the  manner  of  this 
sclerectomy.  It  is  the  only  operation  for  retinal  detachment  that 
has  seemed  to  be  of  any  avail  at  Elschnig's  hands,  and  the  only  one 
he   now   employs.     General   anesthesia.     Free   incision   over,    and 


deutschmann's  operations  663 

down  to,  the  outer  rim  of  the  ()rl)it.  'I'hc  wound  is  widely  retracted, 
the  periosteum  on  the  crest  of  the  rim  is  incised,  and  its  opposite 
leaves  elevated.  With  a  rongeur  a  crescent  of  the  bone,  large  enou.gh 
to  give  access  to  the  outer  wall  of  the  globe  when  the  latter  is  directed 
straight  ahead,  is  excised.  The  periosteum  is  I)r()ught  together  with 
catgut  sutures.  The  external  rectus  is  ex])ose(l,  a  ])air  of  advance- 
ment forceps  is  clamj)ed  on  its  tendon  near  the  muscle  fibers,  and  the 
tendon  is  severed  near  its  middle.  A  lunulate,  or  a  crescent-shaped, 
piece  is  excised  from  the  sclera  just  back  of  the  insertion  of  the  exter- 
nal rectus,  its  greatest  measurement  being  vertical,  and  its  convexity 
directed  backward.  Its  size  will  be  determined  somewhat  by  the 
extent  of  the  detachment  of  the  retina.  Elschnig  begins  this  scler- 
otomy at  the  lower  extremity  of  the  crescent,  using  the  point  of  a 
small  scalpel,  until  the  excision  is  begun,  then  slender,  pointed 
scissors.  As  the  excision  is  carried  upward,  and  the  piece  of  sclera 
is  rolled  upon  itself,  fine  absorbable  sutures  are  passed  through  from 
side  to  side  of  the  resulting  gap,  and  the  scleral  lips  arc  approximated 
so  that  by  the  time  the  sclerotomy  is  completed  the  opening  is  vir- 
tually closed.  The  severed  tendon  of  the  externus  is  reunited  by 
absorbal)le  sutures,  and  the  external  wound  of  the  soft  parts  is  closed 
by  silk  thread. 

Deutschmann's  Operations. — Since  this  surgeon's  experience  in 
the  surgical  treatment  of  detachment  of  the  retina  far  exceeds  that 
of  any  other,  his  methods  deserve  separate  mention.  Of  these 
there  are  two — a  simpler  one  he  calls  bisection  (Durchschneidung) 
and  one,  reserved  as  a  means  of  last  resort,  whereby  injection  of 
calf's  vitreous  is  made  into  that  of  the  affected  eye.  Their  descrip- 
tions are  best  given  in  the  words  of  the  distinguished  operator  himself, 
as  contained  in  a  paper  he  read  July  15,  1909,  at  the  Oxford  Oph- 
thalmological  Congress,  here  quoted: 

"The  simpler  bisection  is  carried  out  with  the  help  of  a  two- 
edged  linear  knife,  as  a  rule  downward,  but  never  upward.  From 
this  it  follows  that  this  operation  is  not  used  in  fresh  cases  in  which 
the  detachment  is  for  the  greater  part  situated  above — one  then 
always  waits  until  the  sub-retinal  fluid  has  gravitated  downward. 
One  directs  the  knife  tangentially  to  the  eyeball,  inserts  it  in  typical 
cases  downward  and  outward,  in  the  anterior  boundary  of  the 
cul-de-sac,  and  bisects  it  horizontally  through  the  eye  so  that  the 
counterpuncture  lies  directly  opposite — thus  downward  and  inward. 
On  the  spot  of  the  counter])uncture   one  pierces  only  the  sclera — ■ 


664      OPERATIONS  FOR  DETACHMENT  OF  THE  RETINA 

spares  the  conjunctiva.  'Hie  knife  is  drawn  ])ack  in  the  same  way, 
the  l)la(le  a  little  turned  on  the  spot  of  puncture,  so  that  the  sub- 
retinal  lluid  can  conveniently  How  away.  The  eye  is  previously 
atropinized  and  is  kejH  under  atrojnne  durinii;  the  whole  of  the  treat- 
ment. A  drop  of  a  5  per  cent,  cocaine  solution  suffices  as  an  anes- 
thetic for  the  operation.  A  bandage — better,  a  celluloid  shield — is 
loosely  applied  for  the  iirst  twenty-four  hours  on  both  eyes,  then 
only  upon  the  operated  one.  The  patient  remains  seven  to  eight 
days  in  bed.  The  operation  is  repeated  according  to  the  reaction 
shown  by  the  eye.  If  the  eye  remains  without  irritation,  the  tension 
normal,  and  if  the  iirst  operation  has  had  an  insulhcient  effect,  a 
second  is  undertaken  after  ten  to  fourteen  days.  This  repetition 
of  the  operation  can,  if  necessary,  take  place  ten  to  twenty,  as  high 
as  thirty,  times  with  sufhcient  intervals.  On  the  other  hand,  the 
treatment  may  cease,  and,  after  a  shorter  or  longer  space  of  time,  be 
again  undertaken.  If  one  proceeds  exactly  according  to  the  direc- 
tions I  have  given,  then  the  operation  is,  as  a  rule,  quite  devoid  of 
danger  to  the  eye.  If  it  appears  as  if  the  first  operation  through  any 
accident  had  an  unfavorable  result,  then  one  must  refrain,  at  any 
rate  at  first,  from  further  intervention.  Among  these  mischances  I 
count  the  accidental  wounding  of  one  of  the  larger  retinal  vessels,  or 
a  hemorrhage  from  an  atheromatous  vessel,  or  the  lighting  up  of 
a  previously  existing  intraocular  inilammatory  process.  The 
typical  course  of  the  bisection  is  such  that  a  cause  of  the  contra- 
indication there  does  away  with  the  iluid  which  pervades  the  con- 
junctiva, while,  on  drawing  out  the  knife  from  the  puncture,  a 
quantity  of  yellowish  fluid  is  evacuated.  It  is  one  of  the  greatest 
rarities  that  this  is  mixed  with  filamentous  fluid,  a  proof  that  there, 
where  I  traverse  the  bulbus,  no  vitreous  body  is  present,  and  that 
thus  I  cannot,  in  fact,  injure  such,  as  I  have  been  accused  of  doing. 
As  regards  the  second  method  of  operation  mentioned  by  me — 
viz.:  the  injection  of  sterile  animal  \itreous  l:)ody  into  the  human 
eye — this  1  reser\e  for  those  eyes  in  which,  according  to  my  ex- 
perience, I  assume  that  the  power  of  sight,  or  the  slight  remains 
of  such,  will  in  a  short  time  be  entirely  destroyed.  Thus,  if  all 
other  methods  ha\e  failed,  if  tension  and  perception  of  light  decline, 
then  llie  injection  of  Nitreous  is  the  correct  ])rocedure.  One  must 
not,  indeed,  ask  too  much  of  it,  but  yet  it  will  l^e  able  to  sa\e  a 
small  })ercentage  of  eyes  otherwise  in  (les])erate  case.  Carried  out 
in  a  strictly  ase])lic  way,  according  to  the  rules  about  to  be  gi\en. 


deutschmann's  operations  665 

it  docs  not  endanj^cr  the  existence  of  the  vyc,  as  it  has  been  said  to 
do.  The  atro])ini/ed  eye  is  aneslheli/.ed  with  a  few  dr()])S  of 
cocaine,  which  fully  suffices  to  allow  one  to  carry  out  the  operation 
without  ])ain.  The  glass  syringe  made  by  the  firm  of  Mahrt  &: 
Horning,  of  Gottingcn,  which  allows  only  a  forward  pushing  of  the 
piston,  is  used;  this  arrangement  was  necessary  in  order  that  no 
deleterious  suction  could  be  ]jractised  u])on  the  contents  of  the  human 
eye  if  by  chance  the  finger  be  removed  from  the  piston;  as  nozzle 
for  the  syringe  one  may  employ  either  a  plalinumiridium  canula, 
or  a  double-edged  knife  canula,  such  as  is  also  made  by  the  lirm 
already  mentioned  under  the  name  "  Kanulen  Messer'' — canula- 
knife.  I  now  use  ready  sterilized  vitreous  body  of  absolutely  fresh 
calf's  eye,  hermetically  enclosed  in  glass  tubes,  supplied  ready 
for  use  by  Dr.  W.  Mielck,  Dammthor-Strasee,  Hamburg.  The 
chemist  supplies  two  kinds  of  calf's  vitreous:  No.  i,  filtration  of 
freshly  boiled  vitreous  body,  afterward  resterilized  by  boiling 
in  hermetically  sealed  glass  tubes — weaker  action.  No.  2,  fresh 
vitreous  body  inspissated  at  40  degrees  Cent.  /;/  vacuo,  residuum 
taken  up  with  physiological  salt  solution — sterilized  by  boiling — so 
that  the  component  parts  of  the  normal  concentrated  vitreous  body 
are  contained  in  it — strongest  action. 

The  technique  of  the  operation  is  as  follows:  In  order  to  bring 
the  retina  as  close  as  possible  to  the  choroid  by  means  of  the  pressure 
of  the  injected  animal  vitreous  it  is  necessary,  naturally,  to  get  rid 
of  the  sub-retinal  fluid.  If  one  uses  the  point  of  the  ordinary 
platinumiridium  canula  then  the  procedure  is  as  follows:  The 
syringe,  filled  with  the  animal  \itreous,  is  best  introduced  in  the 
region  of  the  ora  serrata,  somewhat  outward  and  downward, 
and  given  to  the  assistant  to  hold  quietly  while  the  operator  takes 
the  double-edged  linear-knife  and  makes  a  sim{)le  bisection  down- 
ward, after  the  completion  of  which  he  again  takes  the  syringe  and 
injects  into  the  eye  with  long  careful  pushing  forward  of  the  piston 
1.50  to  2  divisions,  according  to  the  consistency  of  the  eye.  Then, 
the  syringe  is  withdrawn  and  the  puncture  closed  for  some  minutes 
with  toothed  force]js,  in  order  that  none  of  the  fluid  injected  may 
escape  from  the  eye.  If  one  uses  the  syringe  with  the  canula- 
knife,  then  one  inserts  the  syringe  filled  with  the  vitreous  in  just  such 
a  way  without  previous  bisection  as  with  the  double-edged  knife  in 
the  simple  bisection,  that  is,  on  the  stretched  anterior  boundary  of 
the   lower   cul-de-sac:  one  can  introduce  the  jxjint  of  the  canula- 


666      OPERATIONS  FOR  DETACHMENT  OF  THE  RETINA 

knife  up  to  the  spot  of  the  countcrpuncturc;  in  all  cases  one  must 
avoid  moving  the  point  from  side  to  side.  On  the  introduction  of 
the  instrument,  sub-retinal  fluid  flows  away,  and  one  immediately 
presses  the  syringe  piston  forward,  thus  making  the  injection;  the 
point  of  entrance  is  in  this  case  also  held  together  with  forceps  after 
the  removal  of  the  syringe.  After  the  operation  both  eyes  are 
lightly  bandaged  for  twenty-four  hours,  then  one  eye  only.  Further 
measures  depend  upon  the  reaction  shown  by  the  eye.  This  reaction, 
again,  is  dependent  upon  the  concentration  of  the  animal  vitreous  used. 
I  must  here  state,  as  I  have  done  so  often  already,  in  order  to  spare 
my  colleagues  every  unpleasant  experience,  that  they  must  begin 
with  weak  preparations,  and,  since  the  operation  can  eventually 
be  repeated  several  times,  gradually  go  on  to  stronger  ones.  The 
method  teaches  that  the  reaction  of  the  eye  becomes  reduced 
thereby.  For  the  first  injection  one  dilutes  the  vitreous  body  No.  i 
with  equal  parts  of  sterilized  physiological  salt  solution;  for  the 
second,  one  uses  first  pure  vitreous  body,  and  so  on.  Inilammatory 
symptoms,  such  as  may  appear  at  various  periods  up  to  the  eighth 
day  after  the  operation,  can,  as  a  rule,  be  easily  controlled  by  atropine 
and  warm  applications.  If  increase  of  tension  set  in,  one  can  at 
first  wait  quietly — only  when  the  pain  waxes  very  severe,  and  the 
perception  of  light  becomes  somewhat  worse  under  the  influence  of 
the  heightened  tension  should  one  make  a  simple  bisection.  The 
ordinary  course  is,  however,  that,  without  considerable  subjective 
or  objective  symptoms,  the  vitreous  body  becomes  cloudy,  and 
gradually  clears  up  again  completely,  and  even  if  it  assumes  a 
yellowish  abscess-like  appearance  it  becomes  clear  and  normally 
transparent  again  in  the  course  of  a  few  months.  It  is  only  necessary 
to  assist  the  resorption  by  warm  applications  or  by  an  occasional 
salt  injection. 

With  regard  now' to  the  way  in  which  my  methods  act,  I  try 
with  the  animal  vitreous  body  to  obtain  not  only  a  mechanical 
pressure  of  the  detached  retina  against  the  choroid,  but  also  a  firm 
welding  of  both  membranes  on  an  inflammatory  basis  with  simul- 
taneous better  refilling  of  the  eyeball.  That  such  an  object  may 
be  attained  by  this  method  is  proved  by  the  cases  which  have  been 
cured  by  it.  With  regard  to  the  bisections,  I  have  often  said  that  the 
retinal  tension  can  be  reduced  by  the  same,  the  sub-retinal  as  well  as 
the  preretinal  fluid  be  evacuated,  and  smal  adhesions  be  brought 
about  between  the  retina  and  choroid.     It  goes  without  saying  that 


STATISTICS    ON    DETACHMENT  667 

in  cures  obtained  by  my  methods  relapses  can  occur,  just  as  after 
those  obtained  by  spontaneous  cures  and  medicinal  treatment.  In 
such  cases  I  can  use  both  methods  a.^ain  in  order  to  re<^ain  what  has 
been  lost. 

The  principal  thing  is  the  practical  clinical  result,  and  that  speaks 
clearly  enough  for  the  superiority  of  my  oj)crative  treatment.  The 
proof  lies  in  my  statistics.  The  ])est  statistics  known  to  me  are 
those  of  Horstmann  with  6.6  per  cent,  of  cures,  and  those  of  Uhthoff 
with  7.5  per  cent.  I  treated,  up  to  the  ist  of  July,  260  patients  with 
345  eyes  affected  with  detached  retina.  Of  those  345  eyes  I  operated 
upon  302;  the  treatment  w'as  completed  upon  267  eyes.  Of  those 
267  eyes  there  were 

cured  70  =  26.1  per  cent, 

improved    94=35.2  per  cent, 
not  cured  103=38.7  per  cent. 

If  I  subtract  those  patients  on  whom  the  operation  was  performed 
as  an  experiment  only,  without  any  chance  of  recovery  (as  they  were 
informed  before  the  operation)  the  number  of  eyes 

cured  =31 .  i  per  cent, 

improved  =41 .3  per  cent, 
not  cured  =27.6  per  cent. 

Bettremieux,  of  Roubaix,  France,  at  the  19 12  meeting  of  the 
Belgian  Ophthalmological  Society,  reported  tw^o  cures  of  retinal 
detachment  by  his  non-perforating  sclerectomy,  described  in  the 
chapter  on  "New  Operations  for  Glauconea."  Bettremieux  ex- 
plains the  favorable  action  of  sclerectomy  in  detachment  by  his  be- 
lief that  in  this  affection  an  essential  factor  is  the  accumulation,  in  the 
anterior  chamber,  of  aqueous  under  high  pressure,  as  evinced  by 
the  strong  gush,  or  squirt,  of  that  liuid  which  occurs  when  one  makes 
a  corneal  incision  in  a  case  of  recent  retinal  detachment.  Simple 
sclerectomy,  by  lowering  the  tension  in  the  veins  of  the  anterior  part 
of  the  uveal  tract,  favors  the  absorption  of  the  aqueous,  and  modifies 
the  blood  circulation  of  the  eye  in  a  manner  conducive  to  the  cure. 
This  may  also  explain  the  well-known  fact  that  iridectomy  has  a 
salutary  effect  in  detachment,  curing  it  in  a  certain  number  of  in- 
stances. Apropos  of  the  intraocular  tension  in  detachment.  It 
has  become  a  general  belief  that  it  is  reduced,  in  the  vast  majority 
of  cases.     Laubcr  re])ortcd  53  cases  of  the  affection  with  lowered 


668  OPERATIONS    FOR    DETACHMENT    OF    THE    RETINA 

tension  in  48 — about  go  per  cent. ;  while  Deutschmann,  out  of  his  345 
cases,  found  it  reduced  in  but  45 — less  than  13  per  cent.  Doubtless 
much  depends  upon  the  stage,  or  period,  of  the  malady  at  which  the 
tension  is  taken.  Cettremieux,  in  this  connection,  declares  that 
hypotension  of  an  eye  in  which  exists  detachment  is  a  sign  inimical 
to  treatment.  In  exact  accord  with  these  deductions  are  those 
relatixc  to  the  effect  of  subconjunctival  injection  of  solutions  of 
sodium  chloride.  It  is  clearly  established  that  they,  too,  exert  a 
decidedly  beneficial  action  upon  retinal  detachment,  as  also  that 
they  reduce  the  tension  of  the  globe.  It  is  a  rather  curious  fact, 
however,  that  both  iridectomy  and  the  salt  injections  tend  to  raise 
the  tension  of  eyes  that  are  soft  from  uveitis;  as  witness  the  effect  of 
therapeutic  iridectomy,  for  recurrent  iritis,  and  that  of  the  subcon- 
junctival salt  solution  in  traumatic  irido-cyclites.  The  last  I  have 
had  occasion  to  demonstrate  repeatedly  in  the  after-treatment  of 
eyes  from  the  interior  of  which  iron  or  steel  had  been  removed  by 
magnetism.  Therefore,  hypotension  in  an  eye  with  detachment 
may,  on  the  contrary,  be  an  indication — rather  than  a  contraindica- 
tion— that  it  should  be  attacked  by  these  very  agents. 

Wernicke,  of  Uhthoff's  clinic,  in  Breslau,  pubHshed  {Kl.  Mon.  f. 
Agenh.,  Vol.  XLIV,  p.  134)  statistics  of  the  reports,  concerning 
detachment,  in  all  literature  down  to  August,  1905.  There  were  346 
cures,  of  which  24  per  cent,  were  by  operation,  45  per  cent,  by  non- 
surgical treatment,  and  31  per  cent,  were  spontaneous.  Deutsch- 
mann's  statistics  alter  these  somewhat.  How  to  separate  these 
three  classes  definitely  would  be  impossible,  seeing  that  many  of 
the  operated  cases  had  subsidiary  treatment  besides. 

The  non-surgical  measures,  chiefly  relied  upon,  are  absolute  rest 
in  bed,  the  binocular  bandage,  gende  transpalpebral,  digital  massage, 
forced  sweating,  cathartics,  salicylates,  iodides,  atropin  (always) 
and  dionin.  These  are  used  separatelv  or  several,  or  even  all, 
combined,  as  the  sole  means  of  treatment,  or  as  subsidiary  to  oper- 
ati\e  measures. 

Ophthalmoscopic  examination,  exhaustive,  and  oft  repeated,  is 
an  indespensable  preliminary  to  the  intelligent  surgical  management 
of  retinal  detachment.  Among  the  many  important  features  to  be 
thus  ascertained  are,  whetluT  the  separation  is  parlial  or  /o/al. 
Interxention  is  contraindicaled  in  ihc  tola!  form  unless  \ery  recent. 
Whether  ///i,'//  or  low  -i.e.,  whether  llie  detached  ])()rti()n  rises  like  a 
mound,  or  a  succession  of  mounds,  or  lies  closer  to  tlie  clioroid,  in  a 


l.MPOR  lANCi;    OF    ((I'll  111. M.MOSCOI'K  669 

scries  of  small  folds  or  ripples.  'VW-  hi.^h.  hlch  like  kind  is  Uk- 
more  amendable  to  surgical  Irealment;  the  low  hein.i^f,  most  often, 
characteri/ed  by  white  stri])es,  and  knot>of  connective  tissue,  show- 
ing; that  it  is  hopelessly  in  the  embrace  of  the  shrinkin.u;  vitreous. 
Whether  or  not  there  are  membranous  bands,  reaching  well  into 
the  \  itreous,  that  may,  perhaps,  be  suitable  for  Gracfe's  or  Bull's 
discission  methods.  Whether  or  not  the  detachment  is  secondary  to 
a  tumor.  \\'hether  Intc  dclaiJimoil  or  pseudo-ij^lioma,  from  metas- 
tatic choroiditis.  Whether  the  bleb  is  situated  at  the  top,  side,  or 
bottom  of  the  \itreous  chamber.  It  matters  not  in  what  other 
location  it  may  be  found,  it  will  e\entually  settle,  by  gra\itation,  to 
the  bottom.  Deutschmann  counsels  waiting  for  this  settlement  to 
occur  before  beginning  treatment,  but,  like  Wood  in  his  ''System  of 
Ophthalmic  Operations,"  this  is  a  policy  I  cannot  understand. 
Knowing,  as  we  do,  that  the  earlier  we  begin  the  task  of  trying  to 
help  these  cases  the  less  despairing  it  is,  why  lose  precious  time  ? 
There  can  surely  be  no  objection  to  what  Deutschmann  calls 
"pacific"  treatment  before  the  detachment  settles,  nor  can  I  see  any 
to  surgical,  of  the  less  heroic  kinds,  at  least.  Alultiple  punctate 
cautery,  for  example,  or  simple  puncture,  or  even  trephination  with 
the  1.5  mm.  instrument,  together  with  the  most  approved  non-surg- 
ical treatment. 


CHAPTER  XIV. 
OPERATIONS  UPON  THE  ORBIT. 

FOREIGN    BODIES. 


In  view  of  the  peculiarities  of  the  subject,  it  is  thought  best  to  give 
a  few  prehminaries  before  touching  upon  the  operative  measures  of 
foreign  bodies  in  the  orbit.  The  latter  are,  for  the  most  part:  i. 
objects  that  have  entered  the  orbit,  as  fiying  missies  from  explosions, 
such  as  fragments  of  iron  or  stone,  and  leaden  balls;  and  2.  pieces 
left  behind  from  articles  that  have  been  thrust  into  the  cavity, 
like  parts  of  sticks,  stubs,  pens,  pencils,  the  ferules  of  umbrellas, 
etc.  Hence,  those  most  liable  to  these  accidents  are  those  who 
handle  explosives  or  fire-arms  and  children  who  run  with  long, 
pointed  implements  in  their  hands.  A  large  percentage  also  come 
from  stooping  suddenly  amidst  stumps  and  stalks  of  vegetation. 
They  usually  penetrate  by  way  of  the  skin  of  the  lids  or  by  that  of 
the  conjunctiva.  Rarely,  in  their  entry,  they  perforate  the  bony 
wall  of  the  orbit,  and,  still  more  rarely,  enter  through  the  temporo- 
sphenoidal  fissure.  The  distal  extremity  of  the  longer  objects  not 
infrequently  penetrates  one  of  the  adjacent  sinuses  or  the  cranial 
cavity.  It  often  happens  that  little  children,  because  of  their  age, 
and  older  persons,  because  of  their  confusion  at  the  moment  of  the 
accident,  are  not  aware  of  anything  having  entered  in  the  vicinity 
of  the  orbit;  the  only  way  it  is  discovered  being  through  the  secondary 
disturbances  excited  by  the  foreign  body.  Doubtless,  in  many 
instances,  the  intruder  becomes  so  thoroughly  encapsuled  that 
it  never  causes  any  disturbance.  This  can  be  readily  inferred  from 
the  marvelous  manner  in  which,  time  and  again,  the  orbital  tissues 
have  been  known  to  tolerate  foreign  bodies.  Enormous  things 
have  remained  there  for  years  without  producing  the  slightest  reac- 
tion. It  is  probable  that  to  this  cause  arc  due  many  of  the  cases 
of  paralytic  squint,  without  a  history,  and  of  unaccountable  mono- 
lateral  amblyopia.  Yet,  it  is  a  good  thing  for  those  who  are  uncon- 
sciously carrying  around  foreign  bodies  in  their  orbits  that  they  don't 
know  it.     When  they  have  trouble  from  this  source  there  is  time 

670 


FOREU'.N    i5()l)lKS  ()-J  I 

enougli  to  do  somclhing.  Sooner  or  later,  ho\ve\er,  most  of  these 
orbital  foreign  bodies  are  serious  enough  in  their  effects,  causing 
not  only  ocuhir  paralysis  and  blindness  from  injury  to  the  orbital 
nerves,  but  septic  cellulitis,  osteoperiostitis  of  the  walls,  and  even 
meningitis  and  death.  Primary  invohement  of  the  eyeball  is 
relatively  rare. 

Diagnosis. — In  all  the  recent  cases  the  foreign  body  in  the  orbit 
should  be  removed  at  once,  if  practicable.  There  may  be  the  history. 
of  a  foreign  body  without  the  local  evidences,  or  there  may  be  the 
evidences  without  the  history,  or  both  history  and  evidences  may 
be  available.  In  the  first  instances  the  wound  of  entrance  may 
have  healed  or  it  may  be  overlooked.  It  is  surprising  how  large  an 
object  can  pass  through  the  lids  or  conjunctiva  and,  after  a  day  or 
two,  leave  no  apparent  trace.  Or,  if  a  trace  be  found,  how  insignifi- 
cant it  will  seem.  Owing  to  the  position  of  the  eye  at  the  time  of 
the  penetration  and  the  different  position  at  the  time  of  the  examina- 
tion, although  the  injury  may  be  fresh,  it  frequently  happens  that 
a  probe  cannot  be  made  to  follow  the  track.  The  probing  must 
be  carried  out  on  thoroughly  aseptic  principles.  The  probe  can 
usually  find  the  foreign  body  after  a  surrounding  abscess  has  broken 
through  to  the  outside.  Palpation  is  often  useful,  as,  by  judicious 
pressure  at  different  points,  the  sence  of  touch  can  be  made  to 
extend  a  long  way  into  the  orbit.  A\'hen  it  can  be  done,  the  end  of 
the  object  which  has  been  thrust  into  the  orbit  should  be  carefully 
examined  for  signs  that  any  part  has  been  separated  from  it.  In 
children  who  have  developed  exophthalmos  or  other  symptoms 
of  orbital  cellulitis,  for  lack  of  a  diagnosis,  look  for  foreign  body  as 
the  cause.  It  is  estimated  that  in  75%  of  the  cases,  the  foreign  body 
is  situated  beneath  the  upper  inner  angle  of  the  orbit.  If  other 
means  of  diagnosis  fail  to  locate  the  foreign  body,  or,  after  having 
been  located  by  other  means,  then  in  order  to  get  an  idea  of  the  form 
and  size  of  the  object,  one  should  have  recourse  to  the  X-rays. 
The  methods  to  be  followed  with  them  are  precisely  the  same  as 
those  given  for  the  localization  of  foreign  bodies  in  the  eye. 

Surgical  Measures. — As  before  suggested,  those  that  are  not 
likely  to  give  any  trouble  are  best  let  alone,  be  they  recent  or  old. 
The  great  majority  of  the  recent  and  a  goodly  per  cent,  of  the  old 
will,  however,  demand  interference.  Having  located  the  foreign 
body,  it  is  commonly  got  at  by  incision  through  the  skin.  As 
many  structures   are  gone   through   as  is  necessary  to  bring  the 


672  OPERATIOXS    UPOX    THE    ORBIT 

ol)ject  within  reach,  sparing,  as  much  as  possible,  all  those  that  it 
would  be  disastrous  to  wound.  If  it  is  thought  best  to  remove  at  the 
site  of  entrance  and  there  is  still  an  opening,  this  will  need  enlarge- 
ment. The  incision  or  enlargement  extends  horizontally  or, 
better,  parallel  with  the  rim  of  the  orbit,  and  must  be  free  enough  to 
allow  plenty  of  room  to  work.  For  extra  large  foreign  bodies 
situated  close  to  the  roof  of  the  orbit,  it  is  sometimes  the  considerate 
thing  to  shave  the  eyebrow  and  make  the  cut  along  the  mid-line 
of  its  hair-follicles,  so  as  to  hide  the  resulting  scar.  If  suppuration 
is  present,  the  foreign  body  will,  most  likely,  yield  easily  to  the 
traction  of  forceps  or  to  that  of  a  powerful  magnet.  If  not,  the 
cutting  may  have  to  be  extended  down  around  it  before  it  will  come 
without  too  much  violence.  vShould  the  foreign  body  be  of  some 
brittle  material,  easily  broken,  like  dried  wood,  or  wood  and  bark, 
it  is  advisable,  after  removing  a  piece,  to  look  for  more.  Not  long 
since,  the  writer  extracted  in  this  way  three  successive  sections  of  a 
dead  twig,  the  aggregate  length  being  2  1/2  inches.  The  removal 
ha\'ing  been  accomplished,  the  caAity  is  cleansed,  and,  if  aseptic, 
the  tarso-orbital  fascia  is  brought  together  with  absorbable  sutures, 
and  the  skin  opening  closed  with  silk;  if  septic,  a  drain  is  put  in 
and  only  the  extremities  of  these  openings  are  sutured.  In  the  event 
of  the  foreign  body  having  pierced  the  cranium,  unless  suppuration 
is  in  progress  or  the  injury  is  recent,  it  had  better  not  be  withdrawn. 
If  it  only  enters  a  sinus,  it  should  be  removed,  whatever  the  con- 
ditions. When  the  object  is  near  the  apex  or  in  the  spheno-palatine 
fossa  and  the  globe  is  intact,  the  safest  means  of  getting  at  it  would 
be  by  an  osteoplastic  operation,  after  the  method  of  Kronlein.  But 
if  the  state  of  the  eye  is  hopeless,  as  regards  both  vision  and  appear- 
ance, enucleation  and  then  removal  of  the  foreign  body  would  be 
preferable  to  the  Kronlein. 


TEMPORARY  RESECTION  OF  THE  OUTER  WALL  OF 
THE  ORBIT. 

kronlein's  operation. 

About  twenty  years  ago,  two  general  surgeons,  working  inde- 
])endently  of  each  other,  conceived  of  this  operation,  whereby  the 
remoter  depths  of  the  orbit  are  made  much  more  accessible  than  by 
any  former  method.     These  men  were  W^agner,  of  Germany,  and 


KRONLEIN  S    OPERATION 


673 


Kronlein,  of  Switzerland.     Wagner's  idea  was  in  connection  with 
fractures  and  other  injuries  of  the  skull,  among  which  were  foreign 
bodies  lodged  near  the  apex  of  the  orbit,  and  Kronlein's  was  to 
facilitate  the  removal  of  tumors 
of    the    orbit,    particularly    the 
deep-seated      dermoids.         To 
Kronlein    is    due   the  credit   of 
having  evolved  suitable  technic, 
he  calling  the  procedure.  Osteo- 
plastic   Resection    of    the    Outer 
Wall  of  the  Orbit. 

Kronlein's  Operation.— The 
eyebrow  and  the  hair  about  the 
temple  are  shaved  and  the  pa- 
tient narcotized.  The  first  step 
of  the  operation  is  the  incision 
of  the  soft  parts.  This  de- 
scribes an   arc    on    the    temple, 

having     its     convexity      directed    Fig.  353.— Kronlein's  incision  of  soft  parts. 

forward  (Fig.   353).     It  begins 

over  the  semicircular  ridge  of  the  frontal  bone,  above  the  angular 
process,  and  two  centimeters  above  the  fronto-malar  articulation. 
The  topography  of  the  bone  here  is  pronounced,  and  the  different 
features  easily  distinguished  by  feeling.  The  cut  runs  downward 
and  forward  till  about  flush  with  the  outer  rim  of  the  orbit,  where 
it  begins  to  turn  backward,  to  be  carried  along  opposite  the  upper 
border  of  the  zygomatic  arch,  near  the  middle  of  which  it  stops. 
The  first  portion  is  through  only  skin,  fascia,  and  a  little  into  the 
muscle.  The  middle  and  latter  portions  are  down  to  the  bone. 
The  whole  length  of  the  cut,  in  adults,  w^ould  be  about  8  centimeters. 
It  is  important  that  it  be  not  too  small,  also  that  its  course  be  mapped 
out  with  great  precision.  The  periosteum  is  now  incised  along  the 
orbital  rim,  ifted  up  with  a  good  sharp  elevator,  and  loosened  all 
along  the  outer  wall  of  the  orbit.  An  assistant  holds  the  contents 
of  the  orbit  out  of  the  way.  The  loosening  is  continued,  working 
from  above  downward,  till  the  spheno-maxillary  fissure  is  reached. 
This  marks  the  location  of  the  lower  edge  of  the  wedge  of  bone  that 
is  to  be  removed.  It  has  been  generally  recommended  to  stick  the 
elevator  or  a  probe  in  here  to  indicate  the  apex  of  the  wedge — 
Knapp  advises  against  it,  as  encouraging  deep  infection.  Besides, 
43 


674  OPERATIONS  UPON  THE  ORBIT 

instead  of  the  apex  of  the  wedge  being  at  the  forward  end  of  the 
spheno-maxillary  fissure,  it  is  further  back  or  nearly  midway  of 
the  fissure. 

Second  Step. — This  is  the  cutting  of  the  bone,  and  is  accom- 
pHshed  with  the  aid  of  sharp,  flat  chisels,  which  are  sometimes  sup- 
plemented by  delicate  saws,  such  as  band,  wire,  chain,  or  electro- 
motive circular.  Here  an  assistant  may  hold  an  instrument  at  the 
point  that  denotes  where  the  two  converging  bone  cuts  are  to  join. 
This  will  be,  as  before  intimated,  w^ell  toward  the  middle  of  the 
spheno-maxillary  fissure.  The  fissure  is  located  by  the  leaving  off  of 
hard  bone  at  that  place,  and  by  the  peculiar  tense,  yet  elastic,  mem- 
brane that  is  stretched  across  it.  The  base  of  the  wedge  comprises 
the  bridge  of  strong  bone  between  the  orbit  and  the  zygomatic  fossa 
at  the  outer  rim  of  the  orbit  (Fig.  354).  It  extends  from  just  above 
the  frontomalar  suture  downward  to  a  point  nearly  on  a  level  with  the 
lower  orbital  rim,  or  a  distance  of  about  3  centimeters.  The  length 
of  the  wedge  is  about  4  centimeters.  For  severing  the  heavier  bone, 
viz.,  the  angular  process  of  the  frontal  and  the  orbital  process  of  the 
malar,  some  kind  of  saw — Gigli's,  for  example — would  be  a  most  fit- 
ting instrument,  as  it  would  not  only  make  the  task  an  easier  one,  but 
it  would  favor  the  subsequent  coaptation  and  healing,  whereas,  to 
do  it  with  a  chisel,  necessitates  the  taking  out  of  a  chipping  space. 
The  upper  bone  cut  is  made  first,  working  with  the  chisel  from  be- 
fore backward.  The  cut  extends  from  above  the  junction  of  the 
malar  and  the  frontal,  backward  and  downward  at  an  angle  of 
about  45  degrees,  to  the  point  indicated  along  the  spheno-maxillary 
fissure.  When  working  in  the  thin  bone,  it  is  best  to  work  rather 
from  within  outward,  and  to  use  only  the  corner  of  the  chisel,  and 
very  slight  taps  of  the  hammer,  else  the  bone  will  be  shivered,  or  the 
chisel  will  break  through  and  wound  the  structures  beyond.  The 
aim  is  also  to  neatly  cut  the  periosteum  covering  the  outer  side  of  the 
wedge  at  the  same  time.  Care  must  be  exercised  here  or  the  cut 
may  go  too  high  and  enter  the  cranial  cavity.  The  lower  cut  is  made 
next,  beginning  on  the  malar,  about  3  centimenters  below  the  be- 
ginning of  the  upjjer  cut,  and  running  almost  horizontally  back- 
ward to  the  spheno-maxillary  fissure.  The  forward  end  of  the 
fissure  reached,  the  cut  may  be  extended  to  the  apex  of  the  wedge 
with  strong  scissors.  There  should  be  no  dissection  of  the  soft 
parts  from  tlie  outer  surface  of  the  wedge  of  resected  bone.  Now, 
the  whole  lla]),  made  up  of  soft  tissues  and  detached  bone,  is  ready 


KRON'LEIX  S    OPERATION 


675 


to  be  swung  back  out  of  the  way.  All  that  stands  in  the  way  of 
getting  at  the  orbital  contents  is  the  wall  of  periosteum  that  had 
lined  the  inner  aspect  of  the  wedge.  This  is  cut  with  blunt-pointed 
scissors  along  the  lower  border  of  the  external  rectus,  back  of  the 
apex  of  the  wedge,  and  the  two  leaves  are  held  out  of  the  way  with 
tenaculums.  Now  the  retrobulbar  compartment  of  the  orbit  is 
opened  up.  If  the  tumor,  or  foreign  body,  be  on  the  outer  side  of 
the  cone  of  recti  muscles,  it  may  be  removed  at  once,  or  if  it  is  de- 
sirable to  get  at  the  posterior  pole,  or  if  on  the  inner  side,  the  ex- 


Tlu-  he; 


lack  lines  show  bone 


ternus  must  be  got  out  of  the  way.  If  it  suffices  merely  to  pull  it 
aside,  so  much  the  better.  If  not,  it  is  divided  just  where  the 
tendonous  portion  begins,  and  a  substantial  absorbable  suture  is  put 
through  the  two  ends,  for  the  double  purpose  of  holding  them  for 
the  time  being,  and  of  uniting  them  on  the  completion  of  the  opera- 
tion. With  the  blunted  scissors,  the  fibrous  capsule  of  the  globe  is 
incised  so  as  to  expose  the  opticus.  This  nerve  is  the  land-mark. 
By  opening  up  the  wound  to  its  fullest  capacity,  and  with  good  il- 
lumination, the  optic  nerve  can  be  seen  from  its  disappearance  in  the 
sclera  to  its  emergence  from  the  optic  foramen.     During  further 


676  OPERATIONS    UPON    THE    ORBIT 

operation  the  globe  is  drawn  forward  and  inward,  and  the  orbital 
fat  is  pushed  back  with  a  Jager  or  an  Axenfeld  spatula.  Special 
care  must  be  exercised  not  to  injure  the  abducens.  Other  structures 
to  be  avoided  are  the  lacrimal  gland,  the  trochlear  nerve,  the  in- 
traorbital nerve,  and  the  (unnecessary  w^ounding  of)  capsule  of 
Tenon.  Through  breaking  the  capsule  of  the  gland  a  fistula  could 
arise.  Much  traumatism  of  the  capsule  of  Tenon  might  result  in 
crippled  ocular  motility. 

The  orbital  portion  of  the  operation  having  been  completed,  the 
cavity  is  irrigated,  the  cut  ends  of  the  externus  are  approximated  and 
the  suture  secured,  the  aponeurosis  is  nicely  arranged,  the  incision 
in  the  periosteum  is  sutured  with  catgut,  the  big  flap  is  replaced, 
and  the  original  incision  is  closed  with  silk  sutures.  The  usual 
dressing.  The  sutures  are  removed  after  3  or  4  days.  The  healing 
is  usually  prompt.  The  operation,  though  somewhat  tedious,  is 
neither  difficult  of  execution  nor  attended  with  any  peculiar  dangers. 

Modifications. — There  have  been  a  number  of  these,  but  none  of 
them  has  meant  any  radical  departure  from  Kronlein's  method. 
They  have  had  reference  chiefly  to  the  form  and  position  of  the  first 
incision,  and  to  the  size  of  the  wedge  of  bone  resected.  In  fact,  its 
dimensions  in  the  operation  just  described,  are  in  excess  of  those  in 
the  original  operation.  The  cut  in  the  soft  parts  is  also  more  ex- 
tensive. On  occasion,  these  cuts  may  be  made  yet  more  compre- 
hensive. Czermak,  for  instance,  has,  in  this  way,  removed  a  part 
of  the  floor  of  the  orbit,  in  addition  to  the  outer  wall,  employing  a 
tiny  chain  saw,  starting  it  at  the  back  and  cutting  forward  by  pulling. 
Others,  again,  have  gone  much  further,  making  resections,  definitive 
and  temporary,  of  parts  of  the  frontal,  exposing  the  dura,  disarticu- 
lating the  malar,  etc.  Haab's  criticism  of  this  method  is  that  it  is 
getting  outside  the  sphere  of  the  ocular  surgeon,  while  the  simpler 
measure  is  well  within  it.  Schuchardt  and  others  have  suggested 
forms  of  the  saw  and  manners  of  sawing.  Of  course,  to  saw  from 
behind  forward,  a  perforation  must  be  made  through  the  coverings 
of  the  spheno-maxillary  fissure  through  which  to  start  the  saw. 
This  is  the  difficult  and  exacting  part  of  it. 

Of  the  changes  in  the  first  incision,  a  noteworthy  one  is  that  of 
Parinaud  and  Roche.  With  the  view  of  doing  away  with  the  con- 
spicuous scar  left  on  the  temple  by  the  older  method,  these  surgeons 
recommend  a  quadrilateral  flap  with  its  base  directed  forward. 
The  incision  begins  at  the  outer  extremity  of  the  eye-brow,  runs 


INDICATIONS    FOR    KROXLEIN's  677 

horizontally  backward  a  distance  of  5  centimeters,  then  vertically 
downward  5  centimeters,  and,  lastly,  5  centimeters  horizontally 
forward.  The  skin  covering  the  inclosed  area  is  loosened  to  the 
base  and  turned  over  forward;  after  which  the  operation  is  pro- 
ceeded with  as  per  Kronlein.  Haab's  objection  to  this  method  is 
on  the  score  of  possible  interference  with  nutrition  of  the  deeper  flap 
containing  the  bone,  hence  complications  in  healing. 
Indications  for  Kronlein's  operation  are  : 

1.  Retrobulbar  tumors  of  the  orbit,  such  as  dumb-bell  dermoid, 
cysts,  etc.,  including  cavernous  angioma  (Knapp^  and  a  few  others). 
Sattler,2  of  Leipsic,  for  example,  and  Golowin,^  each  has  by  this 
method  actually  ligated  off  and  extirpated  the  affected  vessels  in 
a  case  of  pulsating  exophthalmos. 

2.  Tumors  of  the  optic  nerve  and  of  its  sheath. 

3.  Foreign  bodies  lying  deep  in  the  orbit,  making  their  extraction 
from  in  front  a  menace  to  the  soft  structures,  particularly  those  of 
considerable  volume,  or  those  that  have  become  fast  in  the  adjacent 
bones. 

4.  Phlegmon  of  the  orbit,  especially  when  there  is,  or  is  likely  to  be, 
an  abscess  at  the  apex,  communicating  with  the  posterior  ethmoid 
cells  or  the  sphenoid  sinus,  or  a  strangulating  periostitis  about  the 
optic  foramen,  etc.,  causing  great  lowering  of  vision  without  the  other 
characteristic  signs  of  suppurative  cellulitis. 

5.  Certain  cases  of  syphilitic  or  tubercular  osteo-periostitis  of 
the  orbital  wall. 

6.  To  get  at  the  posterior  pole  of  the  globe  for  operations  upon  the 
sclera  (as  Muller's  resection  for  detachment  of  the  retina)  or  for 
the  extraction  of  intraocular  cysticercus  in  that  region.  This 
last  would  scarcely  ever  need  to  be  resorted  to  in  this  country. 

7.  The  elucidation  of  puzzling  cases  that  could  depend  upon 
some  trouble  in  the  retro-bulbar  orbit. 

8.  The  extirpation  of  the  ciliary  ganglion  in  glaucoma  absolutnm. 

9.  All  tumors  of  considerable  size  lying  near  the  outer  wall  of 
the  orbit,  as,  for  instance,  carcinoma  or  sarcoma  of  the  lacrimal 
gland,  whose  extirpation  from  in  front  would  seriously  endanger 
the  function  of  any  imj)ortant  nerve  or  other  structure.  With 
this  operation  there  is  feeling  and  fumbling  in  the  dark,  risk- 
ing to  wound   the  larger  vessels  at  the  back  of  the  globe,  for  in- 

'  Knapp,  Archives  of  Oph.,  vol.  xxv.  1896. 
2  Sattler,  Graefe-Saemisch,  vol.  vi,  chap.  xi. 
^Golowin,  Zeits.  f.  Augenh.,  iv,  S.  194. 


678  OPERATIONS    UPON    THE    ORBIT 

stance,  thereby  causing  atrophy  of  the  choroid  or  retina  in  an  eye 
whose  sight  might  otherwise  have  been  ])reserved.  One  is  not 
justified  in  sacrificing  the  ajjpearance  of  even  a  bhnd  eye  if  it  can  be 
possibly  avoided. 

THE  REMOVAL  OF  TUMORS  OF  THE  ORBIT. 

Tumors  that  are  favorably  situated,  that  is,  those  that  do  not  lie 
behind  or  below  the  globe,  and  some  of  the  deeper  ones  beneath 
the  roof  or  in  the  upper  inner  angle,  can  be  removed  wdthout 
resorting  to  a  Kronlein  operation  by  incisions  either  through  the 
skin  or  through  the  conjunctiva.  The  various  forms  of  cyst,  and 
congenital  angiomata  may  nearly  all  be  extirpated  in  this  way. 
The  same  may  be  said  with  respect  to  many  of  the  sarcomata  and 
other  tumors. 

The  diffuse,  progressive  angiomata,  especially  in  young  subjects, 
often  admit  of  complete  eradication.  Knapp  has  given  some  excel- 
lent points  in  this  connection.  He  says:  "To  treat  them  with  liga- 
tion, the  injection  of  coagulating  substances,  electrolysis,  galvano- 
causis,  and  the  like  is  very  unsatisfactory.  The  only  way  to  cure 
them  is  by  extirpation.  This  should  be  done  out  of  the  healthy 
surroundings,  avoiding  cutting  of  the  tumor.  If  only  the  afferent 
and  efferent  vessels  are  divided,  which  is,  of  course,  unavoidable, 
the  bleeding  would  not  be  excessive,  for  they,  like  all  other  orbital 
vessels,  are  small  and  soon  stop  bleeding.  To  avoid  cutting  into 
the  tumor,  and  also  to  diminish  the  bleeding  during  the  operation, 
I  have  pressed  a  horn  plate  through  the  cojnunctival  sac,  firmly  against 
the  bony  wall  of  the  orbit  behind  the  tumor.  This  has  served  me  a 
good  ])urpose  in  dealing  with  some  vascular  tumors  in  the  inner 
part  of  the  orbit,  which  had  pierced  the  lids  and  spread  outside  in 
the  skin.  I  extirj)ated  the  orbital  portion,  from  the  posterior 
limit  to  the  inner  surface  of  the  lids,  but  did  not  attack  the  palpebral 
portion  at  all.  There  was  no  more  hemorrhage  than  in  the  extirpa- 
tion of  a  iibroma.  I  expected  the  jjalpebral  ])ortion  to  shrink  after 
its  supply  vessels  had  been  cut  off,  which  it  did." 

The  best  position  for  the  skin  incision  is  somewhere  along  the 
orbital  rim.  In  this  way  the  tumor  is  not  only  made  most  accessible, 
but  the  resulting  scar  is  least  conspicuous.  Above,  it  is  hidden  by 
the  supercilia,  and  in  the  other  parts  of  the  circuit  at  least  masked 
by  the  natural   sulcations  of  the  skin.     If  the  conjimctival  route 


REMOVAL    OF    TUMORS  679 

is  chosen,  it  may  be  made  in  the  fornices.  or,  in  case  of  tumors  at 
the  nasal  side,  vertically  at  ihe  semilunar  fold.  Cutaneous  incision 
external  to  the  inner  canthus  means  cutting  of  the  canaliculi  or  the 
lacrimal  sac,  as  well  as  division  of  the  internal  canlhal  ligament, 
and  is  to  be  avoided  if  possible.  The  sevcrence  of  the  ligament 
is  of  small  moment,  comparatively,  seeing  that  the  fragments  can 
be  united  with  catgut,  and  the  damage  repaired.  For  tumors  at 
the  temporal  side,  when  relatively  small,  and  well  forward,  it  were 
well  to  make  the  first  step  a  free  canthotomy  and  enlarge  the  ensuing 
conjunctival  opening  to  the  required  size.  A  remarkably  clear 
field  for  operating,  in  case  of  large  tumors  beneath  the  roof,  at  the 
supero-nasal  angle,  or  around  the  lacrimal  gland,  may  be  obtained 
by  shaving  the  brow,  then  beginning  the  incision  on  the  med  an  line 
at  the  base  of  the  nose,  (fronto-nasal  suture)  extending  it  first  up- 
ward to  the  level  of  the  supercilia,  thence  through  the  median  line 
of  the  hair-follicles  of  the  eyebrow,  then  curving  downward  along 
the  outer  rim,  to  end  on  a  line  with  the  externalc  anthus.  This 
includes  all  the  tissues  down  to  the  periosteum.  Whenever  possible, 
the  supraorbital  nerve  must  be  spared.  The  wound  is  gradually 
opened  up  into  the  cavity  under  the  roof,  and  the  tlap  thus  formed 
is  turned  down  over  the  palpebral  fissure.  In  this  way  the  writer 
has  removed  a  dumb-bell  cyst  of  unusual  size,  and  a  plexiform 
neuroma  the  size  of  a  man's  thumb — long  axis  fore  and  aft.  These 
tumors  reached  back  so  far  that  in  feeling  with  the  little  finger  for 
their  posterior  attachments  one  could  feel  the  sphenoid  fissure. 
By  pressing  the  contents  of  the  orbit  downward  and  forward  the 
space  is  much  increased  in  the  vertical  sense.  It  is  obvious  that 
it  can  be  similarly  increased  in  other  positions  by  pressing  away  from 
the  tumor,  but  hardly  so  much\s  from  above. 

Congenital  Dermoid  Cyst. — The  favorite  site  of  this  form  of 
tumor  is  beneath  the  "  tail"  of  the  supercilia.  The  tumor  is  usually 
attached  to  the  periosteum  of  the  outer  orbital  rim.  The  primary 
incision  may  be  in  the  midline  of  the  shaved  supercilia,  or  below 
and  parallel  with  this  hairy  growth.  It  is  carefully  deepened  to 
bring  the  cyst  wall  into  view.  If  the  latter  should  be  accidentally 
cut  through,  so  that  part  of  the  sebaceous  or  other  contents  escape 
it  is  best,  at  once,  to  suture  the  opening  firmly  by  stitching  the 
same  carefully  by  over  and  over  sewing  with  strong  thread  till  the 
contents  can  no  longer  escape,  then  using  the  ligature  as  a  handle  to 
manipulate  the  tumor  during  the  further  extirpation.    Carry  the  dis- 


68o  OPERATIONS  UPON  THE  ORBIT 

section  downward  around  the  entire  tumor,  being  careful  not  again 
to  wound  it,  and  finally  to  sever  it  close  down  to  the  bone  by 
shaving  it  off  with  a  blunt-curved  bistoury.  The  point  of  attach- 
ment is  likely  to  be  in  a  sharp  depression  in  the  orbital  rim,  where 
no  part  of  the  sac  must  be  left  behind,  to  serve  as  a  sprout  for  a 
recidivation. 

Technic. — This  can  only  be  given  in  a  general  sort  of  way.  The 
incision,  be  it  cutaneous  or  conjunctival,  is  carefully  deepened  and 
retracted  until  the  tumor  can  be  seen,  or,  at  least,  felt.  It  is 
loosened  from  its  surroundings  mainly  with  the  blunt  dissector 
whenever  possible.  When  this  is  not  practicable,  the  blunt-pointed 
scissors  or  the  grooved  hand-chisel  is  used,  but  always  guided  by 
the  tip  of  the  finger,  being  always  sure  of  the  nature  of  the  tissue 
which  is  being  divided.  Of  the  scissors,  those  curved  on  the  flat 
are  the  most  suitable,  and,  in  snipping,  the  concavity  is  kept  next 
to  the  tumor,  and  only  small  hites  are  taken.  Moreover,  the  scissors 
should  be  small  and  delicate,  so  as  not  to  take  up  unnecessary  room. 
If  the  tumor  is  a  cyst  whose  size  or  shape  increases  the  difficulties, 
it  may  be  drawn  forward  as  far  as  possible  and  an  incision  made  in 
the  wall  just  long  enough  to  allow  of  the  contents  being  pressed 
out — or  sufficient  of  the  contents  to  facilitate  the  extirpation — w^hen, 
before  proceeding  further,  the  cut  is  either  closed  tightly  by  stitching 
with  strong  silk  or  the  sack  is  drawn  forward  at  this  point  in  a  neck, 
around  which  a  ligature  is  securely  tied.  In  either  instance,  after 
the  tying,  the  ends  of  thread  are  left  long,  to  serve  as  handles  by 
which  to  manage  the  tumor.  In  case  of  the  more  solid  growths,  a 
strong  thread  can  be  put  deeply  through  the  forward  part  to  answer 
the  same  purpose.  When  using  forceps  for  holding  the  mass,  they 
should  have  broad  jaws,  and  be  provided  with  a  lock,  so  that  they 
may  be  handed  to  an  assistant  without  risk  of  letting  go  their  hold. 
A  ligature,  however,  insures  a  firmer  hold  and  is  less  in  the  way. 
Every  sign  of  the  tumor  having  been  removed,  the  cavity  is  copiously 
irrigated  with  hot  sublimate  solution,  about  1-2000.  Whenever 
it  can  be  accomplished,  the  tarso-orbital  fascia  should  be  closed  with 
ab.sorbable  sutures.  The  skin  or  the  conjunctival  wound  is  sutured 
with  silk. 

Exostoses  of  the  orbit  are  rarely  fit  objects  of  surgical  inter- 
ference, notwithstanding  the  fact  that  the  aft'ection  is  not  uncommon. 
In  the  great  majority  of  instances  operation  is  contraindicated 
either  because  of  the  exceeding  slow  <irowlh  and  harmlessness  of 


INCISIONS  68 1 

the  tumor  or  because  of  the  danger  that  would  likely  allcnd  ciTorls 
at  its  removal.  Their  favorite  points  of  origin  are  the  roof  and  ihc 
inner  wall  of  the  orbit — just  the  places  that  the  surgeon  must  hold  in 
greatest  respect.  The  next  most  frequent  site  is  the  upper  inner 
angle,  where  the  exostosis  usually  springs  from  the  frontal  sinus. 
Their  recognition  is,  as  a  rule,  not  difficult;  the  sense  of  touch  alone 
being  sufficient  with  which  to  make  the  diagnosis,  on  account  of 
their  stony,  fixed,  lobulated  feel.  Radiography  may  be  valuable 
for  their  diagnosis,  as  w^ell  as  to  get  an  idea  of  form  and  size.  With 
regard  to  their  manner  of  attachment  to  the  orbit,  they  vary  from  the 
broadly  sessile  through  all  grades  of  the  pedunculated,  to  those 
exceptional  ones  that  are  held  merely  by  fibrous  tissue  and  are 
movable.  If  it  can  be  demonstrated  that  one  has  to  do  with  an 
exostosis  that  is  movable  or  has  a  narrow  pedicle,  and  it  is  giving 
inconvenience  or  threatens  any  serious  trouble,  it  is  removable  from 
almost  any  part  of  the  orbit.  This  is  the  kind  that  originates  in  or 
about  the  frontal  sinus.  Not  infrequently,  however,  they  extend 
into  the  cranium  as  well,  and  one  must  beware  of  them.  Most 
of  those  that  arise  from  any  part  of  the  bone  below  the  horizontal 
diameter  of  the  orbit  may  be  attacked  with  impunity,  whether  it 
extends  beyond  this  cavity  or  not;  but  always  for  some  good  reason 
other  than  the  bare  presence,  such  as  interference  with  function, 
deformity,  etc. 

In  operating,  first  lay  the  tumor  bare  by  making  adequate  incisions 
through  the  overlying  tissues,  by  one  of  the  rules  already  given. 
Incise  and  peel  back  as  much  of  the  thickened  periosteum  as  it  is 
possible  to  save.  When  practicable,  one  of  the  tiny  saws  should 
be  used  to  detach  the  growth.  If  not,  mallet  and  grooved  chisel 
or  the  hand-gouge  are  chosen.  The  cutting  with  the  chisel  should 
be  close  down  to  the  base,  the  "chip"  being  taken  from  the  side 
of  the  tumor,  and  the  taps  of  the  hammer  as  light  as  is  consistent 
with  fair  progress.  These  precautions  tend  to  prevent  the  breaking 
out  of  a  hole  at  the  base  of  the  exostosis.  The  abscission  completed, 
the  periosteum  is  carefully  arranged  over  the  site,  stitched,  if 
necessary,  with  catgut,  and  the  openings  in  fascia  and  skin  closed  as 
usual. 

INCISIONS  OF  THE  ORBIT. 

These  are  of  two  kinds,  evacuant  and  diagnostic.  They  are  both 
made  with  the  patient  in  narcosis  if  there  is  no  reason  to  the  contrary. 


682  OPERATIONS  UPON  THE  ORBIT 

Evacuant  incisions,  as  the  name  indicates,  are  made  with  the  object 
of  draining  the  tissues  of  serous  infiltration,  extravasation  of  blood 
or  of  pus.  They  are  most  frequently  called  for  in  abscesses  of  the 
orbit,  and  in  the  more  acute  stages  of  cellulitis;  in  the  latter  not  only 
for  drainage,  but  also  for  their  relaxing  effect  upon  the  tense,  densely 
infiltrated  tissues.  If  relief  is  not  prompt  in  these  cases,  serious 
complications  arise  from  the  pressure,  such  as  necrosis  of  the 
retinal  elements,  necrosis  of  the  cornea  and  lids,  etc.  As  soon  as  the 
swelling  threatens  injury,  therefore,  free  incisions  are  to  be  made 
in  that  part  of  the  orbit  which  is  most  involved,  regardless  of  the 
formation  of  pus,  and  sufficiently  deep  for  drainage,  even  if  they 
penetrate  almost  to  the  apex.  The  manner  of  making  them  is  by 
puncture,  or  thrust;  but,  unless  the  knife  is  fairly  broad,  it  does  not 
suffice  to  draw  it  straight  out  as  it  went  in,  but  a  little  sawing  motion 
is  needed,  or  the  knife  is  tilted  forward  in  withdrawing,  to  extend 
the  cut  slightly.  The  most  suitable  instrument  is  a  long,  slender 
bistoury,  either  straight  or  slightly  curved,  or  a  full-sized  Beer's 
knife.  Both  point  and  edge  must  be  of  irreproachable  keenness. 
The  incision  can  be  started  from  the  conjunctival  sac  for  the  shallower 
parts  of  the  orbit,  but  for  the  deeper,  they  should  start  in  the  skin 
somewhere  within  the  zone  bounded  on  the  inside  by  the  cone  of 
recti  muscles,  and  on  the  outer  side  by  the  rim  of  the  orbit.  The 
safest  places  for  the  profounder  incisions  are  just  beneath  the 
middle  third  of  the  eyebrow  and  any  point  below,  from  that  level 
with  the  outer  canthus  to  that  perpendicular  to  the  wing  of  the  nose. 
The  knife  should  be  held  with  its  flat  toward  the  globe,  and  made 
rather  to  hug  the  bony  wall  of  the  hollow  cone  of  the  orbit  than  to 
encroach  too  much  upon  the  soft  parts;  and,  it  goes  without  saying, 
that  the  most  im])ortant  structures  are  to  be  scrupulously  avoided. 
A  narrow  strip  of  antiseptic  gauze  is  passed  down  to  the  bottom  of 
each  cut  by  means  of  a  tent-probe.  This  should  fit  loosely  that  it 
may  scr\e  as  a  dyain,  and  not  be  stuffed  in  tightly,  to  act  as  a  stopper. 
Diagnostic,  or  exploratory,  incisions  are  such  as  are  made 
with  the  view  of  ascertaining  the  exact  nature  of  a  lesion  hidden  more 
or  less  deeply  from  view.  They  are  executed  by  thrusting  or  lancing, 
as  are  the  evacuativc  kind,  or  by  cutting,  with  the  edge  of  a  scalpel, 
carefully  through  the  tissues.  The  first  mode  would  be  allowable 
only  in  the  event  of  a  liquid  lesion — if,  in  other  words,  distinct 
fluctuation  was  found.  Then  its  quality  might  be  determined  by 
causing  it  to  escape  through  a  simple  puncture.     If,  on  the  other 


F.XKNTKRATIOX  683 

hiiiid,  the  injury  concerned  a  tumescence  of  greater  consistence,  the 
incision  sliould  be  carried  slowly  and  discriminately  through  the 
sticcessive  layers  covering  the  mass,  until  the  latter  is  exposed. 
If  mere  inspection  of  it  enables  one  to  judge  of  its  cliaracter,  well 
and  good.  If  not,  a  portion  may  be  excised  for  microscopic  ex- 
amination. It  must  be  borne  in  mind,  however,  that  certain  of  the 
softer  sarcomata  are  incited  to  tremendous  activity  by  interfering 
in  this  manner,  and  must  be  handled  very  conservatively.  Above 
all,  one  must  not  be  tempted  into  plunging  a  knife  into  one  of  these, 
with  the  view  of  drawing  off  a  supposed  fluid. 

EXENTERATION  OF  THE  ORBIT. 

Also  called  evisceration,  refers  to  an  operation  whereby  the  con- 
tents of  the  orbital  cavity  are  more  or  less  completely  removed,  and 
accordingly,  the  exenteration  is  designated  as  total  or  partial. 
Total  exenteration  means  the  removal  of  the  entire  contents,  in- 
clusive of  all  the  periosteal  lining,  with  sometimes  the  cleaning 
out  of  adjacent  cavities,  such  as  the  middle  nasal  fossa,  the  maxillary, 
frontal,  and  ethmoidal  sinuses,  and  even  the  spheno-maxillary 
fossa  through  the  fissure  of  that  name.  Partial  exenteration  never 
comprises  sacrifice  of  the  periosteum,  and,  in  many  instances,  not 
necessarily  that  of  a  certain  portion  of  the  other  contents.  Either 
method  may  involve  the  removal  of  one  or  both  lids,  provided 
the  disease  at  fault  has  not  already  destroyed  them.  One  or  the 
other  procedure  is  indicated  in  all  cases  where  enucleation  or  a 
Kronlein  operation  cannot  or  has  not  resulted  in  the  eradication 
of  an  orbital  growth  which  may  be  considered  a  source  of  danger. 
The  occasion  for  making  exenteration  is  rare,  and  when  resorted  to 
the  total  form  is  most  often  the  better  to  select.  With  the  perfection 
in  methods  of  diagnosis,  like  the  ophthalmoscope  and  the  micro- 
scope, of  the  surgical  treatment  of  tumors,  to  say  nothing  of  their 
treatment  by  radiation,  the  sphere  of  exenteration  has  become  still 
more  limited.  The  partial  method  is  called  for  in  those  instances 
where,  upon  the  enucleation  of  the  globe  for  an  intraocular  malig- 
nant growth,  it  is  found  that  there  has  been  a  slight  extension  outside 
of  the  sclera;  or  in  cases  of  some  of  the  more  circumscribed  tumors, 
and  those  of  the  optic  nerve  and  its  sheath;  or  cavernomas,  that  have 
got  beyond  the  bounds  of  the  muscle  funnel,  particularly  toward 
the  nasal  side,  as  evinced  by  the  direction  of  the  exophthalmos, 


684  OPERATIONS  UPON  THE  ORBIT 

etc.  By  far  the  greater  number  of  partial  exenterations,  however, 
will  be  undertaken  in  such  affections  as  the  softer  sarcomata  of  the 
orbit,  or  those  of  epithelial  cancer  that  have  extended  deeply  into  this 
cavity;  the  last  purely  with  the  object  of  getting  surplus  tissue  out  of 
the  way,  preparatory  to  treatment  by  radiation.  It  is  quite  possible 
to  change  the  operation  to  the  total  form  after  having  begun  it  as  a 
partial,  and  will  doubtless  be  found  desirable  at  times. 

Technic  of  Total  Exenteration. — Narcosis;  preferably  ether, 
or  by  means  of  ethyl  chlorid  or  nitrous  oxid,  if  the  subjects  are 
children  or  elderly  individuals  with  reduced  vital  force.  The  first 
step  of  the  operation  is  the  making  of  a  canthotomy,  which  should 
extend  at  least  one  centimeter  beyond  the  bony  rim  of  the  orbit. 
The  lids  are  then  everted  and  stretched  wide  apart  with  lid  forceps 
or  clamps.  The  second  step  is  the  circumcision  of  the  soft  parts. 
With  a  highly  convex  scalpel  a  deep  cut  is  made  the  entire  length 
of  the  lower  conjunctival  fornix,  and  down  to  the  bone  forming 
the  corresponding  rim  of  the  orbit.  This  is  continued  upward, 
along  the  outer  cul-de-sac,  inward  above,  and  downw^ard  at  the  nasal 
side,  to  meet  the  first  cut,  carrying  it  boldly  to  the  rim  all  the  way. 
Here  the  lacrimal  canal  is  to  be  avoided.  The  reason  for  beginning 
the  cut  below  is  to  reduce  interruption  from  bleeding  to  the  minimum. 
The  third  step  is  the  loosening  of  the  periosteum.  This  is  incised 
just  on  the  brink  of  the  orbit  all  the  way  around.  The  inner  lip 
of  this  incision  is  loosened  up  sHghtly  at  the  outer  wall,  a  long, 
flexible  spatula  or  elevator  is  inserted,  and  the  loosening  thus  begun 
is  carried  back  to  the  apex,  first  at  the  outer  side,  then  above,  and 
lastly,  at  the  nasal  side.  Whenever  the  spatula  encounters  firm 
resistance  at  any  spot,  the  blunt-pointed,  curved  scissors  are  brought 
to  its  aid.  This  will  occur,  for  example,  at  the  origin  of  the  inferior 
oblique,  at  the  pulley  of  the  superior  oblique,  and  at  the  internal 
check  ligament.  The  membrane  strips  off  so  easily,  that  after 
it  is  well  started,  the  linger  can  help.  In  working  with  the  spatula 
where  the  bone  is  very  thin,  as  over  the  zygomatic  fossa,  without 
and  over  the  delicate  lacrimal  bone  opposite,  every  precaution 
must  be  taken  to  avoid  puncturing.  The  same  with  regard  to  the 
two  large  fissures.  When  the  periosteum  is  thoroughly  loosened 
at  all  points  save  at  the  sphenoid  fissure  and  the  optic  foramen,  the 
nerves  and  vessels  passing  through  those  openings,  together  with 
the  muscle  origins,  constitute  the  remaining  pedicle  of  the  orbital 
contents.     The  fourth  step  is  the  cutting  of  this  pedicle.     A  pair  of 


PARTIAL    FA'EXTERATION  685 

Strong  blunted  scissors  is  introduced  at  the  upper,  inner  angle  and 
pushed  back,  their  extremities  hugging  the  bone,  to  find  and  snip 
the  opticus  as  it  emerges  from  its  foramen,  and  the  upper  and  inner 
muscle  attachments.  The  scissors  blades  must  not  be  shoved  far 
astride  the  nerve,  or  else  the  ophthalmic  artery,  lying  just  to  its  outer 
side,  will  be  wounded.  If  this  happens  there  will  be  a  gush  of  scarlet 
blood.  It  were  better  to  take  more  than  one  snip.  Now  the  cone 
of  tissue  is  held  toward  the  nasal  side,  while  a  pair  of  strongly  curved 
Cooper  scissors  are  inserted  at  the  supero-temporal  roof  and  pushed 
straight  back,  their  convexity  corresponding  to  the  concavity  of  the 
roof,  to  find  and  cut  the  structures  that  pass  through  the  sphenoidal 
fissure  and  the  outer  and  lower  muscle  attachments.  There  should 
be  no  traction  on  the  contents  while  these  cuts  are  being  made.  It 
were  possible  thereby  to  cause  intracranial  hemorrhage.  The 
combination  scissors  and  vessel-clamp  of  Warlomont  or  Bettmann 
have  been  recommended  for  these  acts.  The  greatest  objection 
to    them  is  their  cumbersomeness.     The  exenteration  is  complete. 

The  bleeding  will  be  profuse.  Copious  douching  of  the  cavity 
with  hot  sublimate  solution,  1-2000,  is  now  in  order,  both  for  its 
styptic  and  its  antiseptic  properties.  There  need  be  no  fear  of 
applying  this  freely.  After  this,  a  wad  of  antiseptic  gauze  that  has 
a  ligature  put  through  it  (after  Czermak)  is  pressed  back  into  the 
apex,  not  too  tightly,  a  long  strip  of  gauze  packed  in  on  top  of  it, 
and  a  pad  of  cotton  laid  on  the  lids,  held  on  by  a  strip  tied  around 
the  head.  After  these  have  been  in  for  a  few  minutes,  or  long 
enough  for  the  active  bleeding  to  cease,  they  are  removed — the  wad 
by  its  string — the  cavity  is  lightly  packed  with  one  long  strip  of 
bichlorid  gauze  well  covered  with  vaseline  to  keep  it  from  adhering 
to  the  sides  of  the  cavity,  the  incision  at  the  outer  canthus  is  sutured 
and  the  bandage  is  put  on. 

Should  the  bleeding  persist  in  spite  of  the  tampon,  adrenalin,  the 
persulphate  of  iron,  or  even  the  thermic  cautery  may  be  called  into 
requisition.  The  dressing  should  be  changed  once  or  twice  a  day, 
and  the  orbit  irrigated,  in  order  to  keep  it  sweet. 

The  technic  of  partial  exenteration  is  very  like  that  just  de- 
scribed, the  greatest  difference  being  that  just  sufficient  of  the  cone 
of  soft  parts  is  removed  to  accomplish  the  object  sought — whether 
it  be  a  relatively  small  tumor  mass,  or  to  prepare  the  cavity  for  the 
ray  treatment.  Usually  almost  everything  is  cleared  away  down  to 
the  periosteum.     This  is  accomplished  as  nearly  as  possible  by  stub 


686  OPERATIONS    UPON    THE    ORBIT 

scissors  and  blunt  dissection,  without  the  aid  of  sharper  instruments. 

The  cavity  is  soon  covered  with  a  luxuriant  growth  of  granulations, 
even  partly  filled  with  them.  These,  in  process  of  organization  and 
contraction,  draw  the  lids  inward,  producing  a  ghastly  cup.  This 
can  be,  in  great  measure,  prevented  by  opening  up  the  cavity  be- 
tween the  lids  and  the  orbit  about  the  time  the  granulations  are  at 
the  height  of  their  growth,  and  putting  in  a  lead  or  a  tin  plate  covered 
with  Thiersch  grafts,  raw  side  out — an  artificial  conjunctival  sac, 
as  it  were. 

One  or  both  lids  may  have  to  be  removed  because  of  infiltrations 
of  the  growth,  or,  as  said  before,  they  may  have  been  already 
destroyed  by  the  disease.  The  defect  thus  left  may  be  covered 
later  by  a  pediceled  graft  from  the  temple,  or  by  Thiersch  grafts. 
The  plan  suggested  by  Noorden,  of  covering  the  entire  cavity  Avith 
epithelial  grafts  the  moment  the  operation  is  finished,  does  not  give 
as  good  cosmetic  results  as  when  one  waits  for  the  granulations  to 
partly  fill  the  orbit. 

When  there  was  no  involvement  of  the  lids,  Langebeck,  in  order 
to  preserve  them,  in  a  case  of  very  large  tumor,  circumcised  them, 
except  a  pedicle,  2  centimeters  wide,  at  the  usual  side.  The 
skin  of  this  area  was  dissected  up  to  the  pedicle,  and  turned  over 
the  nose,  to  be  stitched  back  in  place  after  the  enucleation. 

The  writer,  in  the  case  of  a  young  woman  wuth  recurrence  of 
sarcoma  in  the  region  of  the  lacrimal  gland,  after  enucleation  and 
partial  exenteration  had  been  resorted  to  in  vain,  was  enabled  to 
save  the  lids  and  the  conjunctival  sac.  The  incision  extended  from 
about  2  centimeters  below  the  outer  canthus  around  the  upper  rim, 
to  end  in  the  median  line  of  the  nose.  The  flap  thus  outlined  was 
dissected  up  without  injuring  the  conjunctiva,  the  exenteration  made 
and  the  flap  returned.  When  the  lids  are  conserved,  there  is  gen- 
erally an  unseemly  gaping  of  the  palpebral  fissure.  To  obviate  this, 
Kiister  recommends  tarsorrhaphy  of  all  save  the  inner  angle.  In 
such  cases,  the  writer  would  suggest  thorough  resection  of  the  tarsi, 
and  the  preservation  of  the  follicles  of  the  cilia. 

Knapp  says  that  exenteration  sometimes  saves  or  prolongs  life, 
and  sometimes  shortens  it.  And  Panas,  "  Unfortunately,  recidiva- 
tions  are  always  to  be  feared,  and,  in  cases  of  sarcoma,  especially 
glioma,  the  tumor  is  reproduced  with  desperate  tenacity,  and  all 
the  more  quickly  in  proportion  as  the  interventions  are  repeated." 


CHAPTER  XV. 

THE  REMOVAL  OF  FOREIGN  BODIES  FROM  THE 
INTERIOR    OF    THE    EYE. 

Foreign  bodies  within  the  eye  are  threatening  or  dangerous  to  the 
integrity  of  the  organ  in  accordance  with: 

1.  The  degree  and  nature  of  the  traumatism  they  produce  in 
entering.  This  may  be  due  to  direct  wounding  or,  as  in  case  of  hot 
substances,  to  burning. 

2.  The  condition  of  the  injury  with  respect  to  infection,  either 
carried  in  by  the  foreign  body  itself  or  occurring  from  without. 
This  may  vary  from  absolute  immunity  to  the  presence  of  sepsis 
in  the  greatest  virulence. 

3.  Their  location.  Those  lodged  in,  or  in  contact  with,  the 
uveal  tract,  causing  the  greatest  reaction;  next,  those  in  the  vitreous 
body;  then,  the  retina,  and,  lastly,  those  in  the  lens. 

4.  Their  chemical  composition.  Such  as  are  readily  oxidizable, 
like  copper  and  iron,  being  more  potent  for  evil  than  the  noble  metals 
or  even  than  lead  and  zinc.  Copper,  according  to  the  investigations 
of  Leber,  has  the  property  of  giving  rise  not  only  to  violent  uveitis, 
but  also  to  suppuration,  whether  in  connection  with  pathogenic  germs 
or  not.  The  different  intraocular  tissues  exhibit  about  the  same 
relative  tolerance  of  the  decomposition  as  of  the  presence  of  the 
foreign  body. 

5.  The  extent  to  which  they  become  encapsuled,  i.e.,  with  or- 
ganized blood-clot  or  inflammatory  exudations. 

6.  The  duration  of  their  abode.  The  longer  the  time,  the  less 
likely  they  are  to  give  trouble. 

7.  Their  qualities  with  respect  to  diagnosis,  recognition,  or 
localization.  Glass,  for  example,  is  one  of  the  most  difficult  of 
substances  to  find  with  the  eye  and  to  extract  because  of  its  trans- 
parency. True,  it  is  rather  opaque  to  the  X-rays.  Others,  again, 
are  transparent  to  these  rays,  and  escape  observation  through  ob- 
scuration of  the  media.  Still  others,  of  w^hatever  composition,  elude 
all  forms  of  search  by  their  minuteness. 

687 


688  THE    REMOVAL    OF    FOREIGN   BODIES 

Anterior  Chamber. — Probably  less  than  25%  of  the  foreign 
bodies  that  enter  the  eye  find  lodgment  in  this  chamber.  If 
they  have  great  velocity  or  striking  force,  they  mostly  go  beyond, 
and  if  the  contrary,  the  great  majority  fail  to  pass  beyond  the  cornea 
and  sclera.  Many  of  those  that  do  stop  here  are  of  the  transplanta- 
tion kind,  i.e.,  the  extraneous  substance  is  carried  in  by  the  implement 
that  makes  the  corneal  wound,  instead  of  making  an  opening  for 
itself.  In  this  way  ciha,  bits  of  bark,  earth,  etc.,  get  in,  and,  in 
addition,  an  implantation  cyst  of  the  iris  may  develop.  With  the 
exception  of  the  lens,  the  anterior  chamber  tolerates  foreign  bodies 
better  than  does  any  other  part  of  the  eye:  hence,  one  may  be 
more  deliberate  in  putting  into  effect  plans  for  their  removal  than 
if  they  were  in  the  uvea  or  the  vitreous.  If  obscured  by  blood,  one 
may  usually  wait  for  the  latter  to  be  absorbed.  If  the  history 
indicates  the  presence  of  iron  or  steel  within  the  eye,  steps  should, 
meanwhile,  be  taken  to  locate  it,  and  if  found  in  this  place,  it 
should  be  at  once  removed.  Infection  also  requires  prompt  action. 
This  is  not  to  intimate  that  any  foreign  body  should  be  allowed  to 
remain  in  the  anterior  chamber  if  there  is  a  fair  chance  of  removing 
it.  Far  from  it.  The  usual  mode  of  determining  their  presence 
is  by  ocular  inspection,  aided,  if  need  be,  by  direct  and  reflected 
illumination,  and  by  the  binocular,  or  stereoscopic  loupe.  Often 
the  closest  scrutiny  and  the  strongest  focal  illumination  are  necessary. 
Siderosis  of  the  iris,  or  the  characteristic  iron-rust  tint,  is  a  pretty  sure 
sure  sign  that  a  foreign  body  is  in  that  membrane  or  elsewhere  in  the 
uvea,  or  has  been.  In  rare  instances  the  foreign  body  may  be  got  out 
through  the  wound  of  entrance,  though  this  may  have  to  be  enlarged ; 
if  of  iron,  with  a  magnetized  probe,  with  the  tip  of  a  hand  magnet,  or, 
without  inserting  an  instrument,  with  the  giant  magnet;  if  nonmag- 
netic, with  Knapp's  spoon  or  with  suitable  forceps.  Nearly  all, 
however,  will  necessitate  incision  at  another  place.  Even  in  case  of 
still  patent  entrance  wounds,  if  the  body  is  small,  and  has  lodged  at  a 
distance  from  the  wound,  it  is  best  to  make  an  incision  at  a  near-by 
point.  The  removal  is  facilitated  if  the  keratotomy  lies  close  down 
to  the  iridic  angle,  so  that  the  substance  can  slide  out  on  the  iris 
without  being  caught  behind  the  posterior  lip  of  the  cut.  It  is 
desirable  that  the  traction  instrument  pry  the  incision  open  as 
little  as  possible,  to  avoid  needlessly  spilling  the  aqueous.  When 
the  anterior  chamber  is  empty,  the  foreign  body  is  caught  between 
the  iris  and  the  cornea,  and  if  the  foreign  body  is  angular,  or  jagged, 


FROM  THE  ANTERIOR  CHAMBER  689 

it  will  then  catch  or  sink  deeply  into  tlic  iris  and  be  impossible  to 
extricate  without  undue  violence.  A  sharp  projection  may,  in 
this  way,  be  even  driven  through  the  capsule  of  the  lens,  causing 
traumatic  cataract.  If  working  under  such  difllculties,  lay  a  pad  of 
cotton,  wet  with  boric  acid,  over  the  closed  lids,  and  wait  for  the 
secretion  of  more  aqueous.  There  is  no  need  of  hurrying.  In  the 
event  of  its  being  a  bit  of  iron  or  steel,  there  is  no  question  but  that 
it  should  be  got  out  with  a  magnet,  the  one  question  being  as  to 
the  kind  of  magnet,  magnetized  nickel-plated  iron  probe  (or  solid 
nickel),  tip  of  hand-magnet,  or  the  giant  magnet.  Great  attracive 
force  is  rarely  needed,  and  if  exerted  will  often  cause  a  prolapse  of 
iris,  hemorrhage  in  the  anterior  chamber,  and  pain  and  wincing 
on  the  part  of  the  patient.  A  magnetized  probe  is  a  poor  instrument 
as  compared  with  a  properly  constructed  hand-magnet.  There 
would  be  many  an  occasion  on  which  the  control  of  the  current 
causing  the  traction  would  be  of  decided  advantage.  Most  eye 
surgeons  agree  in  pronouncing  the  smaller  magnet  more  fitting 
than  the  larger  when  it  comes  to  work  in  connection  with  the  anterior 
chamber.  Sometimes  a  silver  or  horn  iris  spatula  can  be  of  great 
assistance  by  slightly  prying  open  the  incision,  and  by  holding 
back  the  iris.  Its  use  is  especially  recommended  if  there  is  a  ten- 
dency of  the  cut  to  strip  the  foreign  body  off  the  traction  instrument, 
be  it  probe  or  magnet  tip.  If  the  foreign  body  is  fast  too  tightly, 
either  by  being  pinched  between  cornea  and  iris  or  by  entanglement 
in  the  latter,  to  come  out  with  moderate  attraction,  and  if  waiting  for 
the  chamber  to  reform,  together  with  the  use  of  the  spatula,  do  not 
help  matters,  it  were  better  to  resort  to  the  iris  forceps  for  its  with- 
drawal than  to  throw  on  the  full  power  of  a  giant  magnet.  This 
seizing  the  foreign  body  with  the  forceps  is  of  course  at  the  risk  of 
bringing  the  surrounding  portion  of  the  iris  out  with  it.  The  best  form 
of  iris  forceps  is  that  without  teeth,  having,  instead,  slight  serrations 
athwart  the  inner  aspect  of  the  jaws.  A  forceps  with  teeth  is  apt 
to  make  the  foreign  body  jump  away.  In  seizing  the  foreign  body 
as  little  of  the  iris  should  be  included  as  can  be.  Yet  as  much  as 
comes  out  with  the  forceps  were  best  snipped  off.  A  clean  coloboma 
is  better  than  a  mangled  and  poorly  replaced  segment  of  iris.  An 
iridectomy,  however,  is  by  no  means  inevitable  in  these  cases.  Haab 
declares  that  he  has  not  found  it  necessary  to  resort  to  it  in  extracting 
iron  from  the  anterior  chamber  with  his  large  magnet.  Even  when 
the  fragment  has  lodged  firmly  in  the  iris  at  the  time  of  the  accident, 

44 


690 


THE    REMOVAL    OF    FOREIGN   BODIES 


it  is  sometimes  jjossiblc  to  draw  it  free  into  the  anterior  chamber 
with  the  magnet  before  making  the  corneal  section.  Failing  to  do 
so,  excision  of  the  surrounding  portion  of  the  membrane  is  unavoid- 
able. Indeed,  if  the  bit  of  metal  stands  up  w^ell  above  the  iris,  i.e., 
is  held  merely  by  the  loose,  fibrinous  anterior  portion  thereof,  incision 
and  forceps  extraction  alone  may  better  suffice- — dispensing  with 
the  magnet.  J  saw  my  colleague,  Wilder,  recently  remove  such 
a  foreign  bodv  in  this  manner  without  disturbing  the  iris,  notwith- 


i*i('«  355-  —  L'se  oi  hand  magnet  for  foreign  bodies  in  anterior  i  haniher.      Forefinger 
is  on  niaice  and  break  button. 


Standing  the  fact  that  it  had  been  there  for  a  long  time.  Foreign 
bodies  that  lie  so  as  to  involve  the  uveal  lining  of  the  iris  are  not  so 
well-borne  as  the  more  sui)erricial  ones.  The  above  points  in  technic 
aj)])ly  equally  well  to  foreign  bodies  of  tlie  iris  and  to  those  that  are 
free  in  the  anterior  chamber. 


FROM    THE    POSTERIOR    CIIAMHER  6q 


The  most  suilablc  tip  for  the  hand  ma,L!;nfl  in  this  connection  is 
the  short,  thick,  curved  one,  which  rai)idly  lajicrs  to  a  ])oinl.  Us 
wedge-like  form  serves  to  widely  sejjarate  cornea  and  iris  while  the 
foreign  body  is  being  withdrawn  (Fig.  355).  The  current  should 
not  be  turned  on  until  the  extremity  of  the  tip  is  about  in  contact 
with  the  piece  of  metal. 

In  the  Posterior  Chamber.-  It  has  been  denied  that  foreign 
bodies  ever  imd  their  way  primarily  into  the  ])Osterior  chamber. 
That  its  existence  is  only  assumed,  there  being  really  no  place 
between  the  anterior  capsule  of  the  lens  and  the  posterior  surface 
of  the  iris.  That  those  bodies  that  have  got  in  between  had  hrst 
been  in  the  anterior  chamber  and  secondarily — while  the  patient 
was  in  the  recumbent  posture,  for  instance — slid  over  the  pupillary 
border.  With  this  in  view,  Hodge  advises  that  mydriatics  be 
omitted  when  dealing  with  a  foreign  body  loose  in  the  anterior 
chamber.  A  case  reported  by  the  writer  in  Knapp's  Archives  would 
seem  to  disprove  these  assertions.  It  was  that  of  a  chemist  who  had 
a  glass  flask  burst  in  his  face.  There  was  a  flap-like  perforation 
of  the  cornea,  and  straight  back  of  it  an  abrasion  of  the  lens  capsule, 
but  no  corresponding  trace  in  the  substance  of  the  crystalline.  The 
eye  was  ke])t  under  constant  observation  for  two  weeks,  during 
which  time  there  were  several  exacerbations  of  iritis.  Repeated 
and  exhaustive  searches  were  made  for  a  foreign  body  by  myself 
and  others.  None  was  found.  The  eye  became  quiet  enough  for 
the  patient  to  leave  the  hospital.  He  went  home,  and  shortly  after 
his  arrival,  while  stooping  to  examine  the  grate-bars  in  his  furance, 
he  felt  a  peculiar  startling  sensation  in  the  eye.  The  eye  became 
red  and  painful,  and  he  came  direct  to  my  office.  The  lirst  glance 
showed  a  cube-shaped  bit  of  glass  lying  at  the  bottom  of  the  anterior 
chamber,  having  undeniably  dropped  through  the  pupil  at  the 
moment  the  head  was  lowered  and  the  pain  had  occurred.  It  was 
promptly  removed,  but  with  iridectomy,  and  the  eye  has  given 
no  further  trouble.  Now,  this  man  came  for  treatment  immediately 
upon  receiving  the  injury,  his  pupil  had  not  been  dilated,  neither 
had  he  lain  down.  The  glass  had  evidently  stuck  lightly  to  the 
front  surface  of  the  lens  for  a  short  while,  then  worked  its  way  down 
into  the  ])osterior  chamber. 

In  the  Lens. — The  crystalline  is  wonderfully  tolerant  of  foreign 
bodies.  So  much  so  that  it  will  sometimes  retain  perfect  trans- 
parency for  months,  or  even  years,  with  one  imbedded  deeply  in  its 


692  THE    REMOVAL    OF    FOREIGN   BODIES 

substance.  Even  fragments  of  copper  have  nothing  like  the  dele- 
terious effect  on  it  that  they  have  in  other  parts  of  the  eye.  Often 
the  worst  that  ensues  is  a  cataract,  and  this  may  be  only  partial. 
No  one  would,  of  course,  think  of  making  discission  of  such  a 
cataract  and  thus  risking  to  turn  the  foreign  body  loose  in  the  eye. 
To  extract  it  would  be  justifiable,  but  only  under  certain  conditions, 
among  which  would  be  a  defective  fellow  eye,  signs  of  irritation 
from  the  foreign  body,  or  the  fact  of  the  patient  living  in  a  remote 
district,  etc.  These  remarks  refer  only  to  the  cases  of  known 
foreign  bodies  in  the  lens.  Given  a  transparent  lens  with  foreign 
body  visible  therein  and  a  perfectly  quiet  eye,  certainly  no  interven- 
tion would  be  warranted,  save,  perhaps,  in  the  event  of  the  substance 
being  iron  or  steel.  The  great  surety  and  safety  with  which  the 
magnet  and  a  skillful  operation  could  deal  with  the  situation  might — 
probably  would — overbalance  the  risk  of  leaving  it  there. 

In  the  Vitreous. — The  surgery  of  this  subject  is  of  recent  date. 
This  is  one  of  the  few  fields  that  surgeons  in  ancient,  and  olden 
times  in  general,  fought  shy  of.  The  first  authentic  record  of  the 
removal  of  a  foreign  body  that  had  been  wholly  within  the  vitreous 
chamber  was  that  by  Albrecht  von  Graefe,  about  65  years  ago. 
Then  followed  similar  operations  by  Edouard  Jaeger,  of  Vienna; 
Critchett,  of  London,  and  by  Desmarres,  of  Paris.  The  extraction 
was  with  forceps,  through  the  wound  of  entrance  or  through  a 
scleral  incision. 

It  is  an  etablished  fact  that  at  least  60  to  65%  of  the  foreign  bodies 
that  are  driven  into  the  depths  of  the  eyeball  come  to  rest  in  the 
vitreous  chamber.  Experience  has  proved  that  65  to  70%  of  the 
vitreous  foreign  bodies  are  magnetic,  i.e.,  of  iron  or  steel.  Not  to 
exceed  one-third,  then,  are  left  to  be  treated  by  surgical  measures 
other  than  magnet  operations.  The  latter  will  be  referred  to 
further  on. 

A  foreign  body  in  the  vitreous  is  a  very  grave  atlair,  whatever  its 
nature.  Sooner  or  later,  with  but  few  exceptions,  the  sight  is  lost, 
and  in  the  vast  majority  the  eye  itself  is  destroyed.  Worse  still,  a 
large  percentage  of  the  instances  of  sympathetic  ophthalmia  have 
occurred  in  consequence  of  a  foreign  body  in  the  vitreous  of  the 
fellow  eye.  Some  sort  of  intervention,  then,  is  the  rule.  After 
what  manner  proceed  ?  In  this  connection  are  offered  the  following 
indications  for  intervention  and  abstention,  partly  adapted  from 
Coppcz : 


FROM   THE  VITREOUS  693 

1.  If  the  foreign  body  is  voluminous  and  has  penetrated  with 
considerable  force,  apparently  destroying  the  globe  at  once,  and 
panophthalmitis  is  imminent,  exentcrate  or  enucleate  immediately. 

2.  If  the  traumatism  is  moderate  and  the  media  are  sufficiently 
clear  to  admit  of  seeing  it,  or  it  can  be  definitely  located  by  any  means, 
one  might,  by  an  ample  meridional  scleral  incision,  and  with  the 
aid  of  a  suitable  traction  instrument — say  a  forceps,  a  spoon,  or  a 
hook — and  guided  by  a  mirror  secured  in  front  of  the  eye  of  the 
operator,  essay  to  catch  and  withdraw  it. 

3.  If  the  media  have  lost  their  transparency,  thus  shutting  off 
any  view  of  the  interior  of  the  eye,  and  other  methods  of  localization 
prove  negative,  although  there  may  be  fair  perception  of  light 
and  the  eye  remains  irritable — exenteration. 

4.  If  there  is  no  perception  of  light  and  it  is  known  that  there  is  a 
foreign  body  present,  and  the  eye  is  sensitive  or  irritable,  exenter- 
ation at  once. 

5.  If  an  eye  with  a  foreign  body  in  the  vitreous  is  perfectly  quiet, 
particularly  if  some  time  has  elapsed  since  it  entered,  it  is  probably 
well  encysted.  Here,  whether  the  eye  is  hopelessly  blind  or  not, 
intervention  is  not  indicated.  Instead,  the  patient  is  instructed 
to  watch  closely  and  to  report  any  signs  of  disturbance  in  the  eye 
to  a  competent  oculist.  This  is  particularly  true  of  certain  small 
particles  that  can  be  seen  with  the  ophthalmoscope. 

6.  Not  having  succeeded  in  removing  a  foreign  body  and  if  the 
reaction  is  serious  and  the  ultimate  good  of  the  eye  is  dispaired  of, 
exenteration  or  enucleation,  when  possible,  there  and  then.  It  is 
the  proper  thing  in  all  the  desperate  cases  to  inform  the  patient 
that,  in  case  the  foreign  body  is  not  recovered,  the  removal  of  the 
eye  or  its  contents  might  be  the  only  other  expedient,  and  to  get 
his  consent  to  the  further  operation  if  the  operator  deemed  it  ad- 
visable. As  to  the  choice  between  exenteration  and  enucleation, 
the  first  is  preferable  except  in  cases  where  there  would  be  risk 
through  its  selection  of  overlooking  a  dangerous  foreign  body  in 
the  orbit. 

In  all  recent  cases  it  is  most  imperative  that  steps,  looking  to  the 
riddance  of  the  eye  from  a  foreign  body  be  taken  at  the  earliest 
moment  possible.  The  same  may  be  said  of  the  old  cases  that  have 
but  lately  become  inflamed  because  of  the  presence  of  one.  More- 
over, the  mere  fact  that  foreign  bodies  have  been  known  to  lie  in  the 
vitreous  from  20  to  40  years  without  inciting  mischief  is  no  sign  that 


694  THE    REMOVAL    OF    FOREIGN   BODIES 

this  will  happen  in  any  given  case.     Nor  is  great  length  of  abode 
within  the  eye  of  necessity  a  bar  to  intervention. 

Magnet  Operations. — The  history  of  the  removal  of  foreign 
bodies  from  the  vitreous  has  been  made  mainly  since  the  use  of  the 
magnet  in  the  surgery  of  the  eye.  The  first  tentative  in  this  con- 
nection was  an  ineffectual  one  by  Meyer,  of  Minden,  in  1842.  The 
next,  perhaps,  was  by  Dixon,  of  London,  in  1859,  who  succeeded  in 
removing  part  of  the  blade  of  a  pair  of  scissors  that  had  been  in  the 
vitreous  for  four  weeks.  The  steel  could  be  indistinctly  made  out 
through  the  pupil.  By  means  of  a  large,  permanent  magnet  it  was 
drawn  close  to  the  outer  wall  of  the  globe  and  extracted  with  forceps 
through  a  scleral  incision.  The  eye  was  lost.  It  is  only  since  1870 
that  the  magnet  has  acquired  any  real  importance  in  the  ophthalmic 
world.  Previously,  all  eyes  with  foreign  bodies  in  the  vitreous  had 
been  considered  either  as  doomed  or  else  as  bearing  the  sign 
"hands  off!"  Hence,  no  nstrument  had  been  designed  for  the  ex- 
traction of  a  foreign  body  from  any  part  of  the  interior  of  the  eye. 
Knapp's  spoon-hook  for  foreign  body  in  the  anterior  chamber  was 
about  the  first.  In  1875,  M'Keown,  of  Belfast,  went  further  than 
had  Dixon,  in  that  he  inserted  the  tip  of  a  magnet  through  a  scleral 
opening  into  the  vitreous,  and  succeeded  not  only  in  removing  the 
foreign  body,  but  also  in  saving  the  eye.  This  was  the  first  instance 
in  which  the  magnet  was  made  to  enter  the  eye.  His  example  was 
soon  followed  by  his  compatriots,  Snell  and  MacHardy,  who 
published  articles  commending  the  method.  The  idea  was  taken 
up  by  Knapp,  Griining,  and  others  in  America;  Griining  giving 
a  very  effective  and  convenient  permanent  hand  magnet.  To 
Hirschberg,  of  Berlin,  however,  belongs  the  credit  of  having  rendered 
the  procedure  practicable.  This  was  through  the.  invention,  in 
1879,  of  his  electro-magnet.  Notwithstanding  the  length  of  time, 
this  instrument  has  held  its  own,  and  is  still  the  favorite  of  its  kind. 
It  is  a  most  valuable  acquisition  to  the  eye  surgeon's  outfit,  and  has 
the  remarkable  record  of  having  extracted  up  to  75  and  85%  of 
magnetic  intraocular  foreign  bodies.  Alany  of  the  failures  were 
doubtless  due  to  the  fact  that  the  metal  had  not  been  located.  The 
magnet,  together  with  a  storage  battery  to  energize  it,  can  be  easily 
carried.  Or  it  may  be  put  in  connection  with  the  wires  for  interior 
incandescent  lighting.  Hirschberg  has  recently  had  constructed  a 
more  powerful  hand-magnet.  These  magnets  have  lifting  powers 
ranging  from  1/2  to  2  pounds — sufficient  for  all  ordinary  work — and 


FROM    TIIK    VITREOUS  695 

with  the  addition  of  accumuhilors,  etc.,  their  pull  may  be  still 
further  increased.  It  seems  strange  to  note  that,  as  late  as  1881, 
Dr.  Paul  Berger,  of  Paris,  found  but  31  instances  in  all  literature  of 
extraction  of  a  foreign  body  from  the  posterior  segment  of  the  globe. 
Sulzer,  realizing  that  the  horse-shoe  form  given  the  ordinary  per- 
manent magnet  furnishes  the  greatest  relative  tractive  force,  has 
modified  the  Hirschberg  magnet  thus:  The  core  is  of  soft  iron  in 
the  form  of  a  horse-shoe,  with  ends  closely  a])i)roximated  The 
extremity  comprising  the  two  poles  is  made  of  two  separate  parts, 
isolated,  magnetically,  by  a  piece  of  copper,  on  the  opposite  side  of 
which  they  diverge  like  a  fork  whose  two  tines  fit  into  the  members 
of  the  core. 

In  1 88 1,  MacHardy  suggested  approaching  the  eye  supposed  to 
contain  a  magnetic  foreign  body  to  a  large  magnet,  actuated  by  a 
powerful  electric  machine,  with  the  view  of  ascertaining  if  there 
would  be  any  sensation  in  the  organ  indicative  of  the  presence  of  the 
metal. 

In  1886,  Hirschberg  began  his  ^•aluable  series  of  publications 
detailing  his  experiences  and  his  views  relative  to  work  with  his 
electric  hand-magnet  (Fig.  355). 

In  1892,  Haab,  of  Zurich,  conceived  his  ''giant"  electro-magnet, 
and  found  that  with  it  a  magnetic  foreign  body  could  be  drawn  from 
the  farthest  limits  of  the  vitreous  chamber,  through  the  lens  and 
pupil,  into  the  anterior  chamber,  by  the  mere  application  of  the  tip 
of  the  magnet  to  the  cornea.  At  the  International  Congress  at 
Rome  in  1893  he  recommended  the  "giant"  electro-magnet  not  only 
for  diagnostic  purposes,  but  for  the  extraction  of  the  foreign  body 
as  well.  Haab's  great  magnet  consisted  of  a  soft  iron  core,  60 
centimeters  long  and  10  thick,  and  weighing  more  than  75  pounds. 
This  was  wound  thickly  with  small  copper  wire,  the  whole  weighing 
300  pounds.  Obviously,  this  is  too  heavy  an  instrument  for  carry- 
ing. Since  its  appearance,  many  modifications  have  been  manu- 
factured, some  still  more  powerful,  and  others,  while  but  little  in- 
ferior as  to  the  force  they  exert,  are  so  condensed,  as  to  size  and 
weight,  as  to  make  them  readily  portable.  These  are  attached 
to  the  ordinary  lighting  circuits,  of  70  to  no  volts,  having  a  strength 
of  20  to  33  amperes,  with  or  without  rheostats.  The  current  may 
be  either  continuous  or  interrupted.  Storage  batteries  can  be  also 
employed  to  stimulate  them,  the  minimum  current  for  the  ordinary 
giant  magnet  being  one  of  30  volts.     Tlie  large  magnets  have  lifting 


696 


THE   REMOVAL    OF   FOREIGN   BODIES 


forces  varying  from  1/2  pound  to  2  pounds.  They  are  supported 
on  tables,  like  Haab's.  or  suspended  by  pulleys  from  the  ceiling, 
like  Mayweg's,  or  pivoted  by  universal  joints  to  a  wall-bracket,  like 
Volkman's.  One  of  the  handiest  I  have  seen  is  that  of  the  Victor 
Electric  Company,  of  Chicago  (Fig.  356).  It  is  hung  by  a  movable 
articulation  to  an  adjustable  arm,  similar  to  the  davit  of  a  boat. 
This,  in  turn,  rests  on  a  platform  with  rollers.     Its  form  renders  it 


Fig.  356. — Victor  adjustable  magnet  outfit. 

suitable  for  operating  with  the  patient  either  sitting  upon  a  stool  or 
lying  upon  the  operating  table,  whereas,  the  straight  column  support 
is  only  applicable  to  the  sitting  posture.  At  first  costly,  the  price 
has  now  been  so  far  reduced  that  these  magnets  are  within  reach 
of  almost  any  specialist,  and  each  of  them  who  has  not  access  to  an 
eye  hospital  where  the  inslrunu-nt  is  kept,  should  possess  his  own. 


LOCALIZATION  697 

I  consider  a  fixed  support  for  the  magnet  superior  to  a  llexiljle  one, 
like  a  chain  or  wire  or  cord.  It  is  a  disadvantage  to  have  a  swinging 
magnet. 

Both  large  and  small  magnets  are  furnished  with  tips  of  varying 
forms  and  lengths.  To  increase  the  length  of  the  tip,  however, 
and  to  reduce  its  thickness  are  equivalent  to  increasing  the  distance 
of  the  magnet  from  the  eye,  and  as  the  attractive  force  is  in  inverse 
ratio  to  the  square  of  the  distance,  short,  blunt  tips  will,  on  the 
whole,  prove  more  satisfactory.  In  order  to  increase  the  suction 
area,  as  it  were,  or  sticking  surface  of  the  tip,  instead  of  being  round 
or  cylindrical,  they  are  better  made  ovoid  or  elliptic  (in  cross-section). 

Localization. — Taken  as  a  whole,  the  results  of  magnet  opera- 
tions are  not  so  brilliant  as  some  might  be  led  to  imagine — especially 
when  a  liberal  allowance  is  made  for  unreliability  of  statistics. 
According  to  Hurtzeller,  who  has  gone  over  these  very  carefully, 
out  of  313  attempts  to  extract  steel  or  iron  from  the  vitreous,  only 
65%  succeeded.  Of  these,  a  certain  degree  of  vision  was  preserved 
in  22%.  It  is  acknowledged  that  more  than  half  of  the  entire  number 
eventually  came  to  enucleation — how  many  more  are  not  reported. 
Doubtless,  the  number  of  successes  would  have  been  much  higher 
had  the  most  approved  methods  of  localization  been  employed, 
or  could  they  have  been.  This  is  the  greatest  essential.  What 
are  the  means  to  this  end  ?     They  are  : 

1.  Circumstantial  evidence. 

2.  Ocular  inspection. 

3.  The  ophthalmoscope. 

4.  The  sideroscope. 

[  a.  The  fluoroscope. 

5.  The  roentgen  rays.,  i.e.,      h.  The  radioscope. 


c.  Radiography. 

Circumstantial  Evidence. — By  far  the  greater  number  of 
fragments  or  missiles  that  strike  the  eye  are  so  minute,  and  so  lack- 
ing in  velocity  and  impact  that  they  fail  to  enter  at  all.  Of  those 
that  penetrate  the  vitreous  chamber,  the  big  ones  have  mostly 
caused  destruction  of  the  eye  directly  or  indirectly  before  it 
reaches  the  surgeon.  The  vast  majority  of  those  he  is  called 
upon  to  seek  in  the  vitreous,  and  to  extract,  are  small — that  is  to 
say,  just  large  enough  so  that,  when  traveling  at  the  rate  of 
ordinary  flying  particles,  they  have  •  striking  force  sufficient  to 
pierce  the  cornea,   iris  and  lens,  or  the  sclera  and  its  coverings. 


698  TllK    REMOVAL    OF    FOREIGN   BODIES 

Larger  ones,  traveling  with  greater  speed,  such  as  bird-shot,  are 
more  apt  to  pass  through  the  entire  bulbus.  The  circumstances 
of  the  accident,  examination  of  tools,  etc.,  may  give  an  idea  as  to 
the  form  and  size  of  the  foreign  body;  and  the  direction  of  the  flying 
particle  with  reference  to  the  position  of  the  eye  at  the  time  of 
the  injury  may  suggest  its  location.  Upon  the  size  of  the  foreign 
body  depends,  in  great  measure,  the  size  of  the  wound.  But  it 
must  be  remembered,  that  a  long,  slender  projectile  will,  if  it  strikes 
endwise,  leave  but  an  insignificant  wound,  and  vice  versa. 

Inspection. — If  the  injury  is  recent,  there  are  usually  objective 
as  well  as  subjective  signs  of  it.  These  are:  Externally,  redness 
and  swelling  of  the  lids,  and  of  the  conjunctiva,  and  evidences  of  a 
wound.  If  the  latter  is  in  the  cornea,  there  will  be,  internally, 
a  corresponding  one  in  the  iris  or  in  the  lens,  or  in  both,  not  always 
visible.  The  track  of  the  foreign  body  through  the  crystalline  may 
be  in  evidence — it  may  not  be  as  it  is  often  by  way  of  the  zonule. 
There  is  often  blood,  and  sometimes  pus,  in  the  anterior  chamber, 
and  this  may  hide  the  signs  in  iris  and  lens.  When  visible,  these 
consecutive  wounds  give  a  good  idea  of  the  direction  of  the  foreign 
body,  and  something  as  to  its  location.  If  the  wound  is  in  the 
sclera  it,  too,  has  a  story  to  tell  as  to  the  size  and  direction  of  the 
foreign  body.  Again,  inspection  may  fail  of  results  here,  because 
of  swelling  and  inflammation.  It  is  well  to  bear  in  mind  not  to 
give  undue  credence  to  the  statements  of  the  average  patient. 

The  ophthalmoscope,  in  the  relatively  few  instances  when  it 
reveals  the  foreign  body,  is  the  best  means  of  localization  we  have 
for  the  posterior  half  of  the  vitreous  chamber,  as,  in  addition  to 
the  exact  spot,  it  shows  something  of  the  size  of  the  foreign  body 
and  something  of  the  nature  of  the  bed  in  which  it  lies.  It  is  also 
useful  in  tracking  the  metal  through  the  media,  by  means  of  traces 
of  blood,  exudate,  air-bubbles,  etc.  At  times,  when  not  capable 
of  revealing  the  thing  itself,  it  may,  at  least,  indicate  its  hiding 
place.  Rarely  it  shows  siderosis  of  the  vitreous  in  the  vicinity  of 
the  foreign  body. 

The  Sideroscope.— The  first  to  apply  the  principle  of  the 
magnetic  needle  for  the  purpose  of  ascertaining  the  existence  of 
iron  in  the  eye  was  Poolly,  of  Brooklyn,  who,  in  1880,  published 
the  results  of  his  experiments  in  Knapp's  Archives.  Shortly  after- 
ward Thompson  and  Widerman  each  suggested  a  form  of  galvan- 
ometer.    These  contrivances,  while  based  on   true  scientific  laws. 


LOCALIZATION  (h)C) 

proved  insutTicicnl  for  detecting  the  presence  of  any  but  relatively 
large  masses  of  metal.  In  1894,  Gallemacrts  presented  to  the  F'rcnch 
Society  of  Ophthalmology  the  magnetometer  of  Gerard,  which  was 
an  improvement  on  the  instrument  of  Pooley,  it  having  had  the  power 
of  responding  to  a  bit  of  iron  within  the  eye  weighing  as  little  as 
1/2  milligram.  This  should  be  sensitive  enough  of  all  practical 
purposes  of  diagnosis,  seeing  that  the  weight  of  the  particle  is  rarely 
below  2  milligrams.  The  sideroscope  of  Asmus,  which  has  had 
considerable  vogue,  was  still  more  sensitive  than  that  of  Gerard. 
Like  that  of  the  latter,  the  needle  is  suspended  with  a  single  long 
strand  of  the  silk-worm's  web.  The  only  material  difference  is  that 
in  the  Asmus  sideroscope  the  ordinary  magnetic  needle  is  inter- 
changeable with  an  astatic  needle.  The  variations  of  the  needle 
are  observed  from  a  distance  of  3  or  4  meters  through  a  telescope 
similar  to  that  used  by  surveyors.  The  greatest  objection  to  this 
form  is  its  extreme  sensitiveness,  making,  when  near  objects  of 
iron  or  trolley  and  arc-light  mains,  for  instance,  its  readings  mislead- 
ing. Hirschberg  is  the  inventor  of  a  sideroscope,  or  "  Eisenspaher," 
somewhat  less  sensitive  and  much  less  complicated  than  that  of 
Asmus.  In  it  he  dispenses  with  the  telescope,  and  has  a  small  lamp 
flame  reflected  onto  the  scale  that  indicates  the  oscillations  of  the 
needle.  The  manner  of  operating  the  sideroscope  is  to  approach 
the  needle  to  different  parts  of  the  globe  and  note  its  deflections; 
these  are  greater  the  nearer  and  heavier  the  piece  of  iron.  It  is 
diflEicult  to  manage.  Knapp,  in  referring  to  the  Asmus  model 
says:  "To  handle  it  requires  the  patience  of  a  saint."  With  Hirsch- 
berg's  also,  the  same  precautions  must  be  taken  relative  to  the 
proximity  of  iron  or  of  electric  currents.  Even  particles  of  iron  in 
the  hair  or  beneath  the  scalp  such  as  iron-workers  are  apt  to  have 
will  affect  the  needle. 

Roentgen  or  X-rays  furnish  the  best  known  means  of  locating 
foreign  bodies  in  the  vitreous  chamber,  whether  the  substance  be  of 
iron  or  of  other  material  opaque  to  them.  From  the  time  of  their 
discovery  by  Roentgen,  of  Wurzburg,  until  1896,  the  refracting 
media  of  the  eye  were  thought  to  be  opaque  to  these  rays.  The 
crystalline,  in  particular,  with  its  index  of  refraction  so  nearly  the 
same  as  that  of  glass,  was  considered  impervious  to  them.  This  was 
the  explanation  offered  as  to  their  invisibility.  In  March,  1896, 
Van  Duyse  made  the  first  radiograph  of  a  foreign  body  in  the  eye, 
and  the  delusion  was  dispelled. 


yOO  THE    REMOVAL    OF    FOREIGN   BODIES 

X-rays  afford  so  far  three  methods  of  application  to  the  local- 
ization under  discussion,  viz. :  fluoroscopy,  radioscopy,  and  radiog- 
raphy. The  first  two  depend  for  their  value  upon  the  properties 
possessed  by  certain  substance  of  becoming  luminous  under  the 
influence  of  the  X-rays,  such  as  the  platino-cyanid  of  barium  and 
calcium  tungstate.  In  the  fluoroscope,  a  small  screen  covered  with 
one  of  these  materials  is  fitted  to  a  dark-chamber  that  can  be  held 
to  the  eyes  of  the  examiner.  In  a  darkened  room  the  screen  is 
placed  close  to  the  eye  to  be  examined,  i.e.,  against  the  face  or  the 
temple.  The  Crooks  tube  is  set  in  operation  from  a  point  opposite, 
and  the  observer  sees  a  skiagram  of  the  eye  and  the  other  tissues 
through  which  pass  the  rays  coming  to  the  screen,  and  he  is  sup- 
posed to  determine  whether,  in  addition  to  the  normal  shadows, 
there  is  that  of  a  foreign  body.  Unless  the  subject  be  a  child,  whose 
bones  are  more  permeable,  or  the  foreign  body  be  rather  large, 
these  methods  are  unsatisfactory. 

Radiography. — This  gives  the  most  exact  and  approved  means 
of  localization  of  any  yet  discovered.  It  owes  its  worth  to  power 
of  the  X-rays  to  make  an  impression  upon  an  ordinary  sensitized 
photographic  plate.  The  skiagram  is  thrown  onto  the  plate  and, 
after  ordinary  development  of  the  latter,  is  reproduced  in  negative 
form,  i.e.,  the  shadows  are  the  clearer  or  lighter  places.  A  positive 
printed  from  this  constitutes  the  radiograph.  When  viewed  from 
the  glass  side  of  the  negative,  the  lights  and  shadows  appear  in  their 
true  relations — not  reversed,  so  that  a  positive  is  not  always  needed. 
There  are  three  ways  of  utilizing  the  radiograph  for  the  localization 
of  foreign  bodies  in  the  eye  and  orbit.  These  may  be  desig- 
nated as: 

1,  The  graphic. 

2,  The  stereoscopic, 

3,  The  geometric. 

I.  The  Graphic. — This  consists  in  making  two  exposures  with 
the  eye  at  the  same  distance  from  the  tube,  but  with  a  change  of  90° 
in  the  view-point.  For  the  right  eye,  for  example,  the  plate  would 
be  placed  against  the  right  temporo-palpebral  region  and  the  tube 
at  the  left — this  for  the  first  exposure.  For  the  second,  the  order 
would  be,  the  plate  against  the  closed  lid  of  the  right  eye  and  the  tube 
back  of  the  head,  and  slightly  to  the  right  side,  in  both  instances 
having  the  point  of  emission  of  the  rays  as  nearly  as  possible  in  line 
with  the  center  of  the  eyeball  that  is  exposed.     The  two  views  will 


LOCALIZATION  7OI 

give  the  approximate  ])()silion  of  the  foreign  body  with  resj)ect  to 
the  center  of  the  globe  and  to  the  sclera,  provided  certain  guide- 
marks  are  employed  in  connection  with  the  exposure,  and  a  control 
radiogram  of  about  the  same  aged  subject,  with  limits  of  the  globe 
outlined  (Fig.  373)  be  used  in  the  viewing.  This  is  the  quickest 
way,  and  sufiEiciently  accurate  for  most  cases.  It  would  ha\e  to  be 
an  urgent  case,  with  the  necessary  apparatus  at  hand,  that  could 
not  wait  for  it.  The  localization  could  be  effected,  if  need  be,  on 
the  w^et  plate  immediately  after  fixing.  Two  circles,  each  with  a 
radius  of  about  1/2  inch  (somewhat  smaller  for  a  child),  could  be 
struck  on  the  film  or  the  glass,  its  position  regulated  by  the  guide- 
marks  and  by  the  control  picture.  One  of  the  best  indicators  of 
the  position  of  the  globe  in  the  radiograph  is  one  of  the  tiny  wire 
eye-masks  of  Webster  Fox,  particularly  the  one  having  a  circle  to 
fit  round  the  cornea.  With  this  in  place,  and  having  the  eye  fix 
an  object  so  as  to  make  the  circle  coincide  or  parallel  with  that 
of  the  circle  of  the  cornea  base,  a  fairly  accurate  guide  is  obtained 
for  plotting  the  sclera  in  both  views.  It  must  be  seen  to  in  the  lateral 
exposure  that  the  plate  is  parallel  with  the  sagittal  plane  of  the  eye, 
and,  in  the  other,  that  this  plane  is  perpendicular  to  the  plate. 

2.  The  Stereoscopic. — This  method  involves  the  psychic  element 
that  is  concerned  in  binocular  single  vision.  In  other  words,  it 
gives  to  the  otherwise  flat  skiagram  its  third  dimension,  enabling 
one  to  perceive  the  relative  positions  of  the  objects  there  outlined  in 
relief  or  perspective  as  well  as  laterally.  The  points  of  emission 
of  the  X-rays  from  the  tubes  during  the  exposure  are  separated 
horizontally  by  a  distance  corresponding  to  that  between  one's 
eyes,  the  rays  from  each  made  to  fall  on  its  own  half  of  the  plate, 
thus  producing  a  double  radiograph.  The  resulting  skiagram  is 
viewed  with  a  stereoscope.  The  process  is  well  adapted  to  physical 
examination  elsewhere,  but  p  oorly  to  that  now  under  consideration 
chiefly  on  account  of  lack  of  definition  because  of  the  smallness  of 
the  object  sought,  of  the  heavy  bone  structures  through  which  the 
rays  must  pass,  and  the  feeble  illumination. 

3.  The  Geometric. — This  method  is  based  on  the  principles  of 
geometry  as  applied  to  mathematics;  that  is,  the  result  is  obtained 
by  the  construction  of  diagrams  or  actual  working  models,  together 
with  numerical  calculation.  There  have  been  a  number  of  plans 
worked  out  on  these  lines  by  different  individuals,  some  simpler, 
some  more  complicated;  some  requiring  elaborate  paraphernalia, 


702 


THE    REMOVAL    OF    FOREIGN    BODIES 


some  scarcely  any  beside  the  X-ray  apparatus.  They  start  from  the 
same  beginning,  and  all  arrive  at  substantially  the  same  result, 
but  by  different  routes.  As  a  beginning,  two  shadows,  or  projec- 
tions, of  the  foreign  body  in  connection  with  the  shadows  of  two  or 
three  other  near-by  objects  of  known  position,  are  photographed 
on  the  same  plate.  Both  exposures  are  made  with  a  single  tube, 
which  is  moved  a  definite  distance  between  the  two,  or  they  are  made 
simultaneously,  by  using  a  pair  of  tubes.  The  exact  location  of  the 
foreign  body  is  then  determined  by  triangulation.  The  result  is 
accurate  to  a  degree,  in  all  of  them.  Only  two,  as  being  among  those 
most  often  chosen,  will  be  dwelt  upon  at  any  length  here.  One  is  by 
Sweet,  of  Philadelphia,  and  another  by  Guilloz,  of  Nantez, 

Method  of  Sweet. — Sweet,  of  Philadelphia,  has  designed  a  local- 
izing method  consisting  of  two  metal  indicators,  one  pointing  to  the 

center  of  the  cornea  and  the 
other  situated  to  the  outer 
canthus  at  a  known  distance 
from  the  first.*  Two  expo- 
sures are  made  in  order  to 
give  different  relations  of  the 
shadows  of  the  indicators  and 
of  the  body  in  the  eyeball,  one 
with  the  ray  tube  horizontal 
or  nearly  so  with  the  plane 
of  the  indicators,  and  the 
other  with  the  tube  below 
this  plane. 

The  principle  of  this  method 
may  be  understood  from  the 
prospective  drawing,  Fig.  357. 
Rays  coming  from  the  light 
situated  at  A  cast  shadows  of 
two  ball-pointed  rods  and  an 
object  in  the  eyeball,  and  give  the  view  shown  on  the  surface  C. 
In  this  instance  the  tube  is  in  front  of  the  vertical  plane  of  the 
two  indicators,  and  consequently  the  shadow  of  the  center  ball  will 
be  thrown  back  of  that  of  the  outer  ball.     When  the  light  is  carried 

*  Tlic  in(>tli()(ls  of  vSwoct  ami  flu-ir  description  are  taken  partly  from  the 
work  of  Hansell  ami  Sweet  on  "Diseases  of  the  Ej'c,"  and  partly  from  a  paper 
read  l)y  Sweet  at  the  meeting  of  the  American  Ophthalmological  Society, 
July,  1 '.)()'.». 


^r 


Fig.  357. — Principle  of  method  of  localization. 
(Hansell  and  Sweet.) 


SWEET  S    LOCALIZATION  JO,:; 

below  Ihc  plane  of  Ihe  two  indicators,  the  shadows  of  the  two  rods 
are  formed  on  the  surface  D,  and  the  shadow  of  the  foreign  body  in 
the  eye  assumes  a  new  position.  It  the  distance  of  one  of  the 
indicating  rods  from  the  center  of  the  cornea  is  known,  and  the 
distance  between  the  two  indicators  is  measured,  the  j)osilion  of 
the  metal  in  the  eye  may  be  determined,  since  the  shadow  of  the 
foreign  body  preserves  at  all  times  fixed  relation  to  the  shadows 
of  the  indicating  balls  in  whatever  position  the  light  is  placed. 

Accurate  localization  requires  that  the  axis  of  the  eyeball  shall  be 
parallel  with  the  two  indicators  and  with  the  photographic  plate, 
that  one  of  the  indicating  balls  be  opposite  to  the  center  of  the 
cornea  and  at  a  known  distance  from  it,  and  that  both  indicators  are 
at  a  measured  distance  from  each  other.  The  plate-holder  and  in- 
dicators have  been  combined  into  a  special  apparatus  which  is  bound 
to  the  side  of  the  head,  as  shown  in  Fig.  358.  The  arrangements 
of  the  parts  of  this  apparatus  are  such  that  the  indicators,  while  freely 
adjustable,  are  always  parallel  to  each  other  and  to  the  plate,  and 
the  two  balls  are  perpendicular  to  the  plate  and  15  cm.  distance 
between  their  centers  when  the  apparatus  is 
in  place.  It  is  necessary  that  the  patient 
rotate  the  eyeball  to  bring  the  ocular  axis 
parallel  with  the  plane  of  the  photographic 
plate,  and  that  the  operator  adjust  the  indica- 
tors so  that  the  center  ball  is  opposite  to  the 
center  of  the  cornea. 

To   determine   the  position   of  the  foreign 
body  in  the  eve,  two  circles  are  drawn  repre-        Fig.  358.— Indicating 

•^  '     '  i  apparatus  secured  to  side 

senting  the  horizontal  and  vertical  sections  of     of  head.    (Hansel!  and 
the  normal  adult  eyeball,  and  upon  these  are     "^^'^^  ' 
marked  the  situation  of  the  indicating  balls  at  the  times  the  radio- 
graphs are  made. 

Lines  are  drawn  through  the  shadow  of  each  of  the  indicating 
balls  on  the  two  radiographs.  On  the  negative  made  with  the  tube 
horizontal  and  parallel  with  the  plane  of  the  indicators,  a  measure- 
ment is  made  of  the  distance  the  shadow  of  the  metallic  body  is 
above  or  below  the  shadow  of  each  of  the  indicators.  This  distance 
is  entered  above  or  below  the  spots  representing  the  two  indicators 
on  the  diagram  of  the  vertical  section  of  the  eyeball.  Thus,  in  the 
radiograph  (Fig.  359)  the  distance  of  the  foreign  body  below  each 
indicator  (OS  and  NS)  is  entered  below  the  spots  A  and  15,  front 


704 


THE    REMOVAL    OF    FOREIGN    BODIES 


view,  Fig.  360.  A  line  drawn  through  the  points  C  and  D  gives 
the  direction  of  the  X-rays  at  the  time  the  shadow  of  the  foreign  body 
was  cast  upon  the  plate. 

Similar  measurements  of  the  distance  the  shadow  of  the  foreign 
body  is  below  the  shadow  of  each  of  the  indicators  are  made  on  the 
second  negative,  and  these  measurements  are  likewise  entered  below 
the  points  A  and  B,  representing  the  two  balls  on  the  vertical  sections 
of  the  eyeball.  These  measurements  are  AF  and  BF.  A  line 
drawn  through  the  points  E  and  F  gives  the  direction  of  the  rays 
u'hen  the  second  negative  was  made.  Since  these  two  lines  in- 
dicate the  plane  of  the  shadow  of  the  foreign  body  at  each  exposure, 
the  intersection  of  the  lines  must  be  the  location  of  the  metal  in  the 


Fig.  359. — Radiograph  made  with  tube  near  plane  of  indicators.   (Hansel!  and  Sweet.) 

eye  as  measured  above  or  below  the  horizontal  plane  of  the  globe 
and  to  the  temporal  or  nasal  side. 

To  determine  the  distance  of  the  foreign  body  back  of  the  center 
of  the  cornea,  the  negative  made  with  the  tube  horizontal  is  taken, 
and  the  distance  is  measured  that  the  shadow  of  the  ball  opposite 
the  center  of  the  cornea  lies  posterior  to  that  of  the  external  ball. 
This  distance  is  entered  directly  above  the  external  ball  on  the 
diagram  representing  the  horizontal  section  of  the  eyeball.  A  line 
drawn  from  K  through  he  center  ball  gives  the  direction  of  the  rays 
at  the  time  the  radiograph  was  made.  On  the  same  negative  is 
measured  the  distance  that  the  shadow  of  the  foreign  body  is  back 
of  the  shadow  of  each  of  the  indicators,  and  these  distances,  B  J 


SWEET  S    LOCALIZATION 


7°: 


and  A  H,  are  entered  on  the  diagram.  A  line  drawn  llirou.i^h  ilie 
points  J  and  H  and,  since  this  line  represents  the  plane  of  the  shadow 
of  the  foreign  body,  the  point  at  which  a  perpendicular  drawn  from 
the  situation  of  metal,  as  shown  on  the  vertical  section  of  the  eyeball, 
intersects  this  line  indicates  the  situation  of  the  body  back  of  the 
center  of  the  cornea.  If  the  position  of  the  tube  from  the  eye  has 
been  measured,  its  distance  is  indicated  on  the  line  drawn  from  K 
through  the  center  ball  A.     A  line  through  J  to  this  point  indicates 


HoTizantal 


M 


Front  view. 


Side  VIEW 


Fig.  360. — Diagram  of  position  of  foreign  body  in  eyeball.    (Flanscll  ond  Sweet.) 

the  divergence  of  the  rays.  This  means  of  determining  the  position 
of  the  plane  of  shadow  of  the  foreign  body  is  more  accurate  than 
when  the  measurement  is  made  of  the  shadow  of  the  body  above 
each  of  the  balls,  and  should  be  followed  especially  if  the  body  is 
some  distance  away  from  the  anterior  segment  of  the  globe  or  is  in 
the  orbit. 

If  the  foreign  body  has  passed  into  the  orbit,  the  rotation  of  the 

eyeball  to  insure  parallelism  of  the  ocular  axis  with  the  plane  of 

the  plate  leads  to  a  slight  error  in  the  determination  of  the  position 

of  the   metal.     To   eliminate  this  error  necessitates  a  knowledge 

45 


7o6  THE    REMOVAL    OF    FOREIGN   BODIES 

of  the  angle  of  the  orbit  with  the  plate  or,  its  equivalent,  the  amount 
of  deviation  of  the  eyeball  from  the  primary  position  and  the  con- 
sideration of  this  angle  in  plotting  the  diagrammatic  circles 
representing  the  eyeball. 

The  indicating  apparatus  is  secured  to  the  side  of  the  head 
corresponding  to  the  injured  eye,  and  the  tube  placed  about  12  or 
15  inches  to  the  opposite  side  and  slightly  forward.  The  patient 
is  in  the  recumbent  posture  to  insure  steadiness  of  the  head.  After 
the  indicating  rods  have  been  adjusted,  the  patient  fixes  an  object 
about  5  to  10  feet  distant,  so  placed  that  the  visual  axis  of  the 
injured  eye  shall  be  parallel  to  the  photographic  plate.  An  exposure 
of  from  one  to  two  minutes  will  clearly  outline  the  bones  of  the  orbit 
and  secure  a  shadow  of  any  body  opaque  to  the  rays  in  the  eyeball 
or  in  its  neighborhood. 

Sweet's  New  Localizer. — At  the  meeting  of  the  American  Oph- 
thalmological  Society  in  July,  1909,  Sweet  presented  a  simplified 
method  of  localization.  The  new  form  of  apparatus  exhibited  in 
this  connection,  while  it  embodies  the  same  principles  as  that  just 
described,  is  so  constructed  that  it  relieves  the  operator  of  the 
necessity  of  making  measurements  from  the  radio- 
graphs or  of  drawing  any  lines  to  represent  the 
planes  of  shadow.  "In  the  new  apparatus  the 
planes  of  shadow  of  the  foreign  body  are  accu- 
rately determined  by  the  instrument  without  the 
Image  of  cross-  necessity  on  the  part  of  the  operator  of  taking 
wire  and  cornea,     measurements  from  the  plates  or  in  drawing  lines 

(Sweet  ) 

on  the  chart.  The  tube-holder,  indicating  ball, 
and  plate-holder  are  upon  a  movable  stage,  and  therefore  preserve  a 
known  relation  to  each  other  which  does  not  vary.  The  angle  of  the 
rays  with  the  eyeball  and  the  distance  of  the  tube  from  the  plate 
are  always  the  same,  so  that  one  indicator  is  sufiicient,  and  this 
consists  of  a  small  steel  ball  supported  in  a  metal  ring.  The  setting 
of  this  ball  opposite  the  center  of  the  cornea  is  made  by  means  of 
adjusting  screws  conveniently  placed  on  the  frame  of  the  instru- 
ment. Accuracy  in  the  measurement  of  the  distance  of  the  in- 
dicating ball  from  the  center  of  the  cornea  is  secured  by  means  of  a 
telescope  and  reflecting  mirror.  The  mirror  gives  an  image  of  a 
cross-wire  and  a  lateral  image  of  the  cornea.  Through  the  telescope 
the  obscrwr  adjusts  [hv  iuslrunK'nl  until  the  image  of  the  cross- 
wire  is  in  direct  contact  with  the  image  of  the  summit  of  the  cornea. 


SWEETS    LOCALIZATION 


707 


(Fig.  361.)  When  the  adjuslnienl  is  made,  the  indit  atini^^  hall  is 
exactly  10  mm.  from  the  center  of  the  cornea.  A  miniature  incan- 
descent lamp,  mounted  in  an  adjustable  shade,  illuminates  the  side 
of  the  nose  of  the  patient,  insuring  a  well-lighted  image  of  the  cornea 
and  cross-wire. 

"Instead  of  a  ball  of  cotton  or  other  oljject  for  h.xation,  as  in  the 
older  method,  a  circular  mirror  is  placed  at  a  distance  of  12  inches 
above  the  injured  eye.  'JMie  patient  gazes  in  the  mirror  and  sees  a 
reflected  image  of  the  injured  eye  and  the  circular  celluloid  disk 
with  the  steel  indicating  ball  in  its  center.     After  the  ball  has  been 


Fig.  362.— (Sweet.) 

adjusted  to  a  point  opposite  the  center  of  the  cornea  of  the  injured 
eye,  the  patient  by  fixing  the  ball  with  the  seeing  eye  prevents  any 
movement  of  the  eye  during  the  exposures  and  holds  the  visual  line 
of  the  injured  eye  parallel  with  the  plate. 

"In  order  to  shorten  the  time  of  making  the  radiographs  and 
lessen  the  possibility  of  any  movement  of  the  patient  or  apparatus 
in  changing  plates,  the  two  exposures  in  the  new  apparatus  are 
made  upon  one  plate,  metallic  shutters  protecting  those  portions 
of  the  plate  which  are  not  to  be  exposed  to  the  rays. 


7o8 


THE    REMOVAL    OF    FOREIGN   BODIES 


"The  tube-holder  contains  the  usual  cylindrical  lead  glass  shield 
for  protecting  the  operator  from  the  action  of  the  rays,  with  the 
customary  lead  diaphragm.  The  central  orifice  of  the  diaphragm 
is  covered  with  aluminum,  which  offers  little  obstruction  to  the 
rays,  but  lessens  the  risk  of  any  unfavorable  action  of  the  rays  upon 
the  patient  and  guards  against  possible  damage  to  the  eyes  in  the 
event  of  breakage  of  the  tube.  The  tube-holder  slides  upon  a 
graduated  rod,  and  the  first  exposure  is  made  with  the  indicator  at 


Fig.  363.— (Swx'ct.) 

zero,  in  which  position  the  rays  pass  in  a  direction  corresponding 
with  the  horizontal  plane  of  the  eyeball.  The  second  exposure  is 
made  with  the  tube  at  its  farthest  point  to  the  right  or  left  of  the 
first  position,  depending  upon  which  eye  is  to  be  examined.  The 
illustration  (Fig.  362)  gives  a  view  of  the  complete  apparatus. 

"Since  the  relative  position  of  the  tube  in  reference  to  the  indicating 
ball  and  the  photographic  plate  remains  fixed  and  known,  it  is 
readily  seen  that  the  direction  of  the  X-rays  in  passing  through  the 
eyeball  must  follow  a  definite  course,  which  is  always  the  same  for 
the  two  separate  exposures.  It  is,  therefore,  possible  to  indicate 
on  the  localization  chart  the  direction  of  the  rays  at  the  two  exposures, 


SWEET  S    LOCALIZATION 


7OQ 


and  this  has  been  done  in  the  chart,  a  copy  of  which  is  rei)rodLiced 
in  Fig.  364,  reduced  in  size  one-half.  Only  those  lines  representing' 
rays  2  mm.  apart  are  reproduced,  but  each  line  is  drawn  with  the 
required  amount  of  divergence  to  indicate  the  rays  as  coming 
from  a  point  the  distance  of  the  tube  from  the  photographic  plate. 
"Method  of  Employing  the  New  Localizer.— The  apparatus 
is  arranged  as  shown  in  Fig.  363.     The  patient  lies  with  the  liead 


Chart  For  DrSweet's  Imprcved  Eye  Localizer. 

Xodefty  Roentgen  Mani/jcc1arin<j  Co 

EateoT 


Fig.  364. — Localization  chart,  with  lines  representing  course  of  the  .r-ravs  one- 
half  actual  size.     (Sweet.) 


on  a  platform  of  hard  fibre,  with  a  pillow  beneath  the  shoulders 
and  a  small  sand-bag  under  the  head  and  neck.  The  upright 
supports  for  holding  the  head  are  now  adjusted  by  means  of  the 
wheel  I,  and  the  jointed  part  of  the  apparatus,  J,  containing  the 
indicator  is  brought  down  in  position.     The  indicating  ball,   G, 


7IO  THE    REMOVAL    OF    FOREIGN   BODIES 

is  now  roughly  adjusted  until  it  is  opposite  the  center  of  the  cornea 
and  about  12  or  15  mm.  distant.  The  patient  looks  with  the  unin- 
jured eye  into  the  mirror,  M,  and  fixes  upon  the  iris  or  cornea  of  the 
injured  eye,  or,  better,  upon  the  indicating  ball  in  the  center  of  the 
celluloid  disk.  The  indicating  ball  is  now  carefully  adjusted  directly 
over  the  corneal  center  by  means  of  the  wheels  2  and  3,  and  the 
correctness  of  the  position  verified  by  observation  through  an 
opening  in  the  mirror,  M.  The  operator  then  adjusts  the  light  of 
the  small  electric  lamp  so  that  the  side  of  the  nose  next  the  injured 
eye  is  illuminated,  but  the  light  is  not  thrown  into  the  eye.  With 
this  area  lighted  it  is  possible  to  see  clearly  through  the  telescope, 
T,  when  the  cross-wire  is  exactly  tangent  with  the  summit  of  the 
cornea.  The  movement  necessary  to  secure  this  position  of  the 
wire  is  made  by  means  of  the  adjusting  wheel  4.  When  the  image 
of  the  cross-wire  touches  the  image  of  the  corneal  summit,  the 
indicating  ball  is  exactly  10  mm.  from  the  eyeball. 

"The  photographic  plate  is  inserted  beneath  the  spring  clips, 
C  C,  the  shutters,  S  S,  moved  so  that  the  center  area  is  open  (Fig. 
362),  and  the  tube-holder  adjusted  to  the  zero-point  on  the  sliding 
scale.  The  current  is  turned  on,  and  one  exposure  made.  The 
tube-carriage  is  then  moved  to  the  limit  of  the  shding  rod,  always 
in  the  direction  of  the  chin  of  the  recumbent  patient  (to  the  end 
marked  R  if  the  radiographs  are  made  of  the  right  eye,  and  to  L 
if  of  the  left  eye).  The  upper  shutter  is  moved  to  cover  the  exposed 
central  portion  of  the  plate  and  uncover  the  upper  unexposed 
portion.  The  current  is  again  turned  on  and  the  second  exposure 
made.  The  time  of  exposure  for  the  second  picture  should  be 
about  one  and  a  half  times  that  of  the  first,  to  allow  for  the  increased 
distance  of  the  tube  from  the  eye. 

"After  the  plate  is  developed  it  is  placed  in  the  frame,  P  (Fig.  362), 
containing  the  key-plate  or  focal  coordinates  (Fig.  365),  with  the 
film  side  of  the  radiograph  next  to  the  key-plate.  The  radiograph 
is  moved  until  the  shadow  of  the  indicating  ball  of  the  first  exposure 
is  in  appcjsition  willi  the  middle  ball  on  the  key-plate  and  the  heavy 
horizontal  line  of  the  ra(liogra])h  parallel  with  the  horizontal  line 
on  the  plate.  Holding  the  frame  to  the  light,  there  is  noted  the 
position  occupied  by  the  shadow  of  the  foreign  body  with  respect  to 
the  vertical  lines  of  'C  and  'D.'  A  reading  is  made  of  the  line 
or  lines  which  pass  through  the  body,  and  this  is  transferred  to  the 
corresjjonding   lines   of   the   'C  or  'D'   scale  of   the   chart,  to   the 


SWEET  S    LOC'AMZATIOX 


711 


right  or  left  side,  depending  on  which  eye  is  under  examination. 
Without  moving  the  plate  the  'E'  reading  is  similarly  made  and 
transferred  to  the  chart.  To  take  the  'A'  or  'B'  reading,  the 
plate  is  shifted  slightly  until  the  image  of  the  indicating  ball  on  the 
second  exposure  coincides  with  the  'Right'  or  'Left'  ball  of  the 
vertical  coordinates  'A'  or  'B.'  The  line  or  lines  of  the  'A' 
or  'B'  coordinates  which  cross  the  shadow  of  the  body  are  noted 


TIlCHT 


Lett 

I.. 


20 


30 


^ B—^ 

—/I f— 

10      1       10 

u  - 

-t 

—  c 

— t — ^  - 
10    1     10 

0 

— 

fi 

10 

"" 

" 

1 

— 

- 

" 

" 

" 

■ 

■■ 

-  ■ 

" 

■ 

- 

" 

■ 

■ 

- 

^  ■ 

'~ 

... 

■■ 

■ 

■ 

— 1 

\~ 

' 

' 

20 


30 


to 


^50 

Fig.  365. — Plate  showing  focal  coordinates  three-fourths  actual  size.      (Sweet.) 

and  indicated  on  the  'A'  or  'B'  lines  of  the  chart.  The  hori- 
zontal coordinate  'E'  should  be  the  same  in  both  readings.  If 
the  focus  point  on  the  anode  of  the  tube  was  accurately  set  by  the 
cross-lines  on  the  lead-glass  shield  of  the  tube-holder,,  the  images 
of  the  indicating  ball  on  the  plate  will  coincide  simultaneously  with 
those  on  the  transparent  key-plate,  and  it  will  then  not  be  neces- 
sary to  reset  the  plate  to  read  the  position  of  the  'A'  and  'B' 
coordinates. 

"After  the  three  readings  have  been  transferred  to  the  chart,  the 
point  of  crossing  of  the  'A'  or  'B'  and  the  'C  or  'D'  lines  is 
found,  which  gives  the  location  of  the  foreign  body  in  reference  to 
the  front  view  of  the  eyeball,  indicating  its  situation  above  or  below 
the  center  of  the  cornea  and  to  the  nasal  or  temporal  side  of  the 
vertical  plane.  Where  a  vertical  line  from  this  point  crosses  the 
'E'  reading  on  the  horizontal  section  of  the  globe  it  gives  the 
depth  of  the  body  in  the  eyeball  or  orljit.     In  bodies  of  large  size 


712 


THE    REMOVAL    OF    FOREIGN   BODIES 


both  ends  should  be  locaHzcd  to  give  the  position  in  which  the  body 
rests  in  the  globe.  The  situation  of  the  body  on  the  side  view  is 
determined  by  transferring  its  measured  depth  from  the  horizontal 
section  and  its  distance  above  or  below  the  horizontal  plane  from 
the  front  view  localization. 

"The  new  apparatus  is  based  upon  the  same  general  principles 
as  was  the  old,  but  its  mechanical  features  eliminate  some  of  the 
errors  that  may  occur  in  the  use  of  the  present  instrument  through 


Fig.  366.- — Radiograph  of  foreign  body  in  eye  three-fourths  actual  size.     (Sweet.) 


carelessness  of  the  operator  in  making  the  measurements  and 
transferring  them  to  the  chart.  The  inexperienced  worker  in  eye 
localization  is  also  relieved  of  the  necessity  of  studying  out  the 
position  of  the  tube  and  the  direction  of  the  lines  of  shadow  at  the 
two  exposures.  The  construction  of  the  new  apparatus  insures  that 
these  factors  are  positively  determined  and  recorded.  The  accuracy 
of  the  localization  depends  only  upon  the  care  with  which  the 
operator  adjusts  the  indicating  ball  opposite  the  center  of  the  cornea 
and  at  the  definite  and  fixed  distance  from  it.  After  the  exposures 
are  made  and  the  plate  developed,  the  determination  of  the  situation 
of  the  foreign  body  is  simply  a  question  of  reading  from  a  key-plate 
and  transcribing  these  readings  to  the  chart." 

Mackensie  Davidson  secures  equally  accurate  results  in  the 
localization  of  foreign  bodies  in  the  eyeball  by  means  of  special 
form  of  ai3j)aratus  and  the  use  of  particles  of  fuse  wire  placed  at 
points  near  the  orbital  margin.     The  planes  of  shadow  of  the  foreign 


LOCALIZATION-    GUILLOZ  7 13 

body  at  the  two  exposures  and  their  point  of  erossin.^^  are  indicated 
by  means  of  threads. 

Method  of  Guilloz. — Two  tubes,  ca[)able  of  separate  adjustment, 
have  their  anticathodes  on  the  same  level.  A  sensitized  i)late, 
enveloped  in  black  paper,  is  placed,  horizontally,  50  centimeters 
below  them.  A  fine  wire  fastened  around  the  plate  gives  the 
projection  of  the  line  joining  the  anticathodes,  and  two  metallic 
guide-marks,  placed  on  this  line,  indicate  the  centers  of  emission. 
Three  metallic  guide-marks  are  glued  about  the  orbital  rim  of 
the  subject,  one  just  external  to  the  supraorbital  notch,  one  directly 
below,  and  the  third  at  the  external  rim.  The  subject  lies  with  the 
side  of  the  head  wdiich  corresponds  to  the  affected  eye  resting  on 
the  plate.  The  eye  is  immobilized  by  having  the  subject  fix  some 
object  immediately  in  front  of  it — not  in  the  median  line. 

The  two  tubes  are  set  in  action,  and  the  exposure  made  to  last 
from  two  to  four  minutes.  Thus  are  obtained  double  shadows, 
or  biconic  projections,  i.e.,  of  the  metallic  markers,  as  also  of  the 
foreign  body.  These  biconic  projections  are  transformed  either 
by  a  diagram  or  by  calculation  into  right-angular  lines  that  give 
the  distance  between  the  markers  themselves  and  their  distances 
from  the  foreign  body.  The  distance  between  the  markers  being 
directly  measurable,  one  thus  obtains  a  verification  of  the  result. 
Moreover,  before  beginning  the  calculations,  or  the  drawing  of  the 
diagram,  it  is  necessary  to  be  assured  that  the  lines  joining  the 
homologous  points  of  the  double  images  are  parallel  with  the  line 
left  on  the  plate  by  the  wire  that  has  been  stretched  across  it. 

Guilloz  has  demonstrated  on  the  head  of  a  cadaver  that  the  method 
is  exact  to  the  fraction  of  a  millimeter.  The  manner  in  which  the 
head  reposes  on  the  plate  does  not  have  to  be  determined  in  accordance 
with  the  findings.  It  is  only  necessary  to  sec  that  tlie  head  and  the 
eye  remain  immovable  during  the  exposure,  a  fixation  apparatus 
not  being  necessary.  Be  it  understood  that  the  degree  of  precision 
that  we  have  indicated  is  that  obtained  geometrically;  this  is  not 
usually  the  case  when  the  localization  geometrically  attained  is 
transformed  to  conform  to  the  three  markers  in  the  anatomic 
localization — it  may  be  by  reason  of  the  variable  dimensions  of  the 
orbit  or  it  may  be  owing  to  the  mobihty  of  the  eye. 

The  distances  of  the  foreign  body  from. the  three  guide-marks 
having  been  determined,  it  remains  to  make  the  anatomic  localiza- 
tion.    This  is  accomplished  with  the  aid  of  markers  by  employ- 


714 


THE    REMOVAL    OF    FOREIGN   BODIES 


ing  an  inslrument  which  is  nothing  more  than  a  compass  with  four 
branches,  each  of  which  may  be  set  for  whatever  inclination  or  what- 
ever length  is  desired  (Fig.  367).  The  head  of  the  compass  is  formed 
of  a  plate  through  whose  center  runs  the  median  branch,  and  carries 
on  its  periphery  the  three  upper  articulations  of  the  arms  that  support 
the  other  branches.  The  central  branch  is  a  graduated,  rectilinear, 
cylindrical  stem,  sliding,  with  light  friction,  in  a  hollow  shaft  one 
centimeter  in  length.  This,  at  its  center,  passes  through  a  copper 
ball  to  which  it  is  soldered,  and  which  works  in  a  spherical  concavity 

situated  partly  in  the  plate 
and  partly  in  a  flange  fastened 
by  three  screws  on  top  of  the 
plate.  A  little  turn  given  to 
one  of  these  screws  renders 
the  articulation  rigid,  by  pres- 
sure, and  permits  only  the 
sliding  of  the  graduated 
branch  in  its  collar.  Each 
lateral  arm  is  biarticulate,  the 
upper  extremity  being  at- 
tached to  the  plate  by  a  ball- 
and-socket  joint  similar  to  that 
described  for  the  central 
branch,  and  which  can  be 
made  rigid  by  the  action  of  a 
thumb-screw.  The  lower 
part  of  each  arm  is  fitted  with 
-Method  of  Guilloz  for  localization  a  hinged  articulation,  carrying 
a  short,  hollow  cylinder, 
through  which  slides  a  lateral  branch,  and  that  is  also  provided  with 
a  thumb-screw  to  make  it  rigid. 

Assuming  that  the  distances  separating  the  guide-markers,  one 
from  the  other,  is  known,  as  also  those  of  the  foreign  body  from 
said  guide-markers,  to  adjust  the  compass  a  triangle,  A  B  C,  is  con- 
structed (Fig.  368),  whose  sides  represent  the  distances  between  the 
guide-markers.  The  points  of  the  lateral  branches  of  the  compass 
are  placed  on  tlie  tlircc  ])oints  of  the  triangle  and  set  with  the  thumb- 
screws. The  central  stem  is  pushed  down  lo  fall  at  the  point  X  in 
the  triangle,  and  the  distanceXA,  XB,  and  XC'  are  found  by  stepping. 
Now,  to  facilitate  the  regulation  of  the  c()m])ass,  take  a  bit  of  per- 


FiG.  367. 
of  foreign  bodies  (iron  or  steel),  in  the  eye. 


T.OCAI.IZATIOX     CriLLOZ 


715 


forated  lead,  X,  attach  to  three  other  bits  of  lead,  A,  H,  and  C,  by 
wires;  the  points  of  the  branches  are  struck  into  the  corresponding 
leads,  and  the  central  branch  is  pushed  down  until  the  wires  are 
stretched.  The  compass  thus  adjusted,  the  distances  are  verified 
by  means  of  ordinary  dividers,  and  the  arrangement  is  perfected  by 
stepping.     The  result  obtained,  the  central  stem  is  set  tight  by  the 


Fig.  368. 

screw  in  the  flange,  and  the  mark  on  the  graduated  scale  that  is 
flush  with  the  top  of  the  collar,  is  noted. 

If  the  compass  were  placed  on  the  subject's  head  the  points  of  the 
lateral  branches  in  contact  with  their  corresponding  guide-markers, 
the  direction  of  the  central  stem  would  indicate  the  position  of  the 


Fig.  369. — Guilloz's  method  of  localization  of  iron  in  eye. 

foreign  body,  for  if  it  were  pushed  down  to  the  point  noted  on  the 
scale,  its  point  would  rest  upon  the  said  body.  The  process  is  not 
only  accurate,  but  simple.  The  shadows  on  the  photographic  plate 
(or  positive),  together  with  the  known  distance  of  the  tubes  from 
the  plate,  furnish  all  the  information  needed  to  determine  the 
situation  of  the  foreign  body. 


7l6  THE    REMOVAL    OF    FOREIGN   BODIES 

The  general  plan  is  illustrated  by  the  accompanying  figure  369: 
Let  B  represent  the  foreign  body  S  S'  the  points  of  emission  of 
the  rays — from  two  tubes  at  once  or  from  the  same  tube  in  different 
positions.  The  conic  projection  of  B  on  the  plate  P  gives  us  the 
two  points  b,  b'.  The  positions  of  S  S'  and  b  b'  are  known,  and  their 
distances,  one  from  another,  are  measurable.  Hence,  to  determine 
the  position  in  space  occupied  by  B,  all  that  is  required  is  to  join 
h'  to  S',  and  h  to  S,  either  by  real  lines,  as  of  wire  in  the  apparatus, 
or  by  lines  traced  on  a  diagram  wherein  the  points  S  S'  and  b  b'  have 
been  placed.  This  first  process  absolutely  determines  the  point  B 
holds  in  space.  Its  relative  position  can  then  be  ascertained  with 
relation  to  certain  guide-marks. 

To  Control  the  Eye.— The  direction  of  the  eye  should  be  the 
same  at  the  time  of  the  exposure  (or  exposures)  to  the  rays  as  at  the 
time  of  the  surgical  intervention.  Omit  this  precaution  and  the 
whole  procedure  of  localization  comes  to  naught.  A  small  sheet  of 
metal  is  pierced  with  a  round  opening  the  size  of  the  cornea.  When 
this  is  placed  in  front  of  the  eye  it  is  easy  to  make  the  circle  of  the 
cornea  correspond  to  that  of  the  aperture.  To  this  sheet  of  metal 
are  fastened  three  legs  or  processes  that  extend  just  to  the  centers  of 
the  guide-marks  placed  on  the  orbital  rim.  At  any  time  that  it  be- 
comes desirable  to  reproduce  the  position  the  eye  was  in  at  the  time 
of  the  exposure,  it  suffices  merely  to  place  the  processes  on  the  cor- 
responding guide-marks,  then  cause  the  cornea  and  the  opening  to 
coincide.  Guilloz  claims  to  have  accurately  located  by  the  foregoing 
method  a  piece  of  steel  weighing  only  i  milligram.  None  of 
the  methods  are  infallible.  The  severest  tests  of  the  two  just  given 
are  when  dealing  with  a  very  minute  foreign  body  situated  far  at  the 
opposite  side  of  the  eye  from  the  tube,  or  in  line  with  the  denser  bone 
shadows  that  are  interposed.    Here  they  may  fail. 

Choice  of  Relative  Positions  of  Head  and  Tube.— To  obtain 
a  radioscopic  view  or  to  make  a  radiographic  exposure  of  the  eye 
that  shall  be  least  obstructed  by  surrounding  bone  are  matters 
worth  considering.  Figs.  370  to  373  are  from  radiographs  of  the 
orbital  region  made  by  Guilloz,  and  are  adapted  from  Volume  IV 
of  the  French  Encyclopedia  of  Ophthalmology.  The  black  circle 
represents  the  globe  of  the  eye.  These  pictures  were  made  witli 
the  view  to  ascertaining,  by  shifting  the  relative  positions  of  tube 
and  head,  how  great  is  the  interference  of  the  heavy  shadows  of 
surrounding  l)one  w^'tli  the  area  occupied  by  the  cyc])all.     The  left 


LOCALIZATION — GUILLOZ 


717 


eye  is  in  question;  i.e.,  the  plate  is  fixed  to  the  left  temple.  In 
each  instance  the  distance  from  the  tube — or  point  of  emission  of  the 
X-rays — to  the  photographic  plate  is  60  centimeters,  and  the  plate 
is  placed  parallel  with  the  sagittal  plane  of  the  head.  In  the  first 
exposure,  Fig.  370,  the  long  axis  of  the  head  was  at  right  angles 


to  the  tube.  About  one-half  the  shadow  of  the  eye  is  covered  by  the 
dense  shadow  of  the  external  rim  of  the  orbit.  Now,  in  proportion 
as  the  tube  is  moved  forward,  or  as  the  head  is  inclined  to  the  right, 
the  circle  representing  the  globe  is  disengaged  more  and  more  from 
the  dark  streaks  of  bone  shadow.     The  second  exposure.  Fig.  371, 


Fig.  371. — At  an  inclination  of  io°. 

was  made  with  the  tube  at  an  inclination  of  10°  to  the  lirst.  Fig. 
372  at  20°,  and  Fig.  373  at  30°.  It  will  be  seen  that  in  the  last 
radiograph  the  globe  stands  out  clearly  defined  in  a  relatively 
shadowless  space.  At  a  still  further  inclination,  the  disengagement 
would  be  even  more  complete,  but  the  distortion  caused  by  the 


7i8 


THE    REMOVAL    OF    FOREIGN   BODIES 


obli(iuity  of  the  ])rojection  would  l)e  so  pronounced  as  to  render  the 
result  valueless. 

The  X-rays  serve  to  locate  most  species  of  wood,  glass,  stone,  and 
all  the  other  metals  as  well  as  iron  and  steel. 

The  proper  distance  of  the  tube  from  the  plate  is  from  40  to  50 
centimeters  (16  to  20  inches).     Since  the  rays  emerge  from  the  anti- 


FiG.  372. — At  an  inclination  of  20°. 

cathode  divergent  like  a  cone,  the  further  away  the  plate,  the  more 
magnified,  yet  the  less  distinct  the  shadows  and  the  longer  the  ex- 
posure. The  center  of  the  anticathode  should  be  in  line  with  the 
center  of  the  rotation  of  the  exposed  eye.     To  have  the  subject  in 


Fig.  373. — At  an  inclination  of  30°. 

the  recumbent  posture  during  exposure  is  conducive  to  accuracy, 
as  the  motions  imparted  to  the  head  by  the  heart,  in  breathing,  and 
by  the  muscles  concerned  in  equilibrium  are  then  most  nearly 
eliminated.  It  is  advisable  to  cover  the  eye  not  concerned — better 
still,  to  bandage  it  firmly.  The  patient  may  lie  on  the  back  with 
the  plate  bound  to  the  temple  and  the  tube  at  the  opposite  side  or 


TECHNIC    OF    MAGNET    OI'ERATIOXS  719 

on  his  side,  with  the  temple  on  the  ])late  and  the  tube  or  tubes 
directly  above.  When  the  foreign  body  has  but  recently  entered 
the  eye,  it  may  be  susceptible  of  movement  in  obedience  to  the  laws 
of  gravity.  It  would  then  be  important  that  the  same  position  be 
assumed  in  exposure  and  in  extraction. 

The  dangers  and  inconveniences  of  the  X-ray  to  both  examiner 
and  examined  should  not  be  ignored.  They  mainly  concern  the 
skin  of  the  operator's  hands  and  the  skin  and  hair  of  the  patient's 
head.  Trophic  disturbances  are  common — brown  discoloration, 
erythema,  etc.  Gangrene,  with  subsequent  deformity  of  the  lingers, 
can  occur. 

Comparison  of  the  Methods  of  Localization. — To  put  it  con- 
cisely, circumstantial  evidence,  the  patient's  statements  or  those  of 
others,  and  ocular  inspection  are  all  very  good  as  far  as  they  go, 
but  cannot  be  trusted  to  any  considerable  extent.  The  ophthal- 
moscope is  preferable  to  any  other  means,  but,  unfortunately,  it  is 
so  handicapped  with  restrictions  that  it  seldom  has  an  opportunity. 
The  sideroscope  has  the  advantage  of  being  ready,  favoring  despatch, 
and  also  of  indicating  whether  or  not  the  foreign  body  is  magnetic. 
Its  use,  however,  is  limited  by  its  sensitiveness  to  surroundings  and 
by  its  inability  to  respond  to  very  small  foreign  bodies  when  situated 
in  the  posterior  segment.  Moreover,  it  takes  no  cognizance  of 
foreign  bodies  other  than  those  of  steel  or  iron  and  is  troublesome 
to  manipulate.  Of  the  X-ray  methods  the  graphic  is  a  method  of 
expedience,  and,  in  common  with  the  others  in  the  same  grou]),  it 
can  make  known  the  presence  of  a  foreign  body  of  other  material 
than  iron  and  gi\es  an  idea  of  form  and  volume.  Radioscopy  and 
fleuroscopy  are  serviceable  on  occasion,  i.e.,  for  the  larger  foreign 
bodies,  but,  as  a  rule,  are  unreliable.  The  objections  to  stereoscopic 
radiography  have  already  been  given.  So  that,  after  all,  geometric 
radiography  is  the  method  of  general  utility,  since  it  tells  nearly  all 
that  any  of  the  others  can  and  tells  it  more  accurately;  though,  as 
has  been  seen,  it,  too,  has  its  limitations,  not  the  least  of  them  being 
the  time  it  consumes.  Yet,  with  everything  at  hand,  the  negative 
radiograph  can  be  produced  in  half  an  hour. 

The  Technic  of  Magnet  Operations, ^It  is  assumed  that  the 
piece  of  metal  has  been  located  in  the  vitreous  by  one  of  the  modes 
just  given,  or  else  that  this  has  been  impracticable  and  that  the 
time  has  come  to  operate.  Shall  it  be  the  smaller,  hand-magnet, 
or  the  giant,  or  both  ?     This  is  a  matter  of  choice  and  circumstance. 


720  THE    REMOVAL    OF    FOREIGN   BODIES 

For  the  case  in  point  we  will  select  the  smaller,  but  have  the  other 
in  reserve,  and  will  discuss  the  pros  and  cons  of  the  two  instruments 
further  on.  Indeed,  those  who  are  in  no  way  prejudiced  may, 
on  occasion,  have  recourse  to  both  at  a  single  sitting.  The  eye  is 
prepared  and  the  patient  is  put  upon  the  table  and  narcotized. 
Unless  there  is  some  good  reason  to  the  contrary,  it  is  best  to  have 
him  asleep,  in  order  to  insure  freedom  from  pain  and  squeezing, 
with  needless  escape  of  vitreous.  If  the  injury  is  recent  and  the 
wound  is  in  the  sclera,  and  the  foreign  body  has  been  located  nearby, 
the  coverings  of  the  globe  are  incised  and  retracted  and  the  bleeding 
is'  stanched.  At  this  stage,  if  the  wound  is  well  back,  fixation 
forceps  are  employed  to  gently  rotate  the  eye  without  pressure. 
The  tip  of  the  magnet  is  inserted  a  very  little  way,  without  previous 
enlargement  of  the  scleral  openings,  if  it  be  adequate.  If  not,  it  is 
extended  sufificiently  with  blunt-pointed  scissors.  When  the  tip 
is  thought  to  be  near  the  metal,  the  circuit  is  completed  by  pressing 
the  button  on  the  magnet,  holding  the  magnet  still  for  a  few  seconds. 
If  the  foreign  body  is  attracted  to  the  tip,  and  is  of  fair  size,  there 
will  be  a  slight  shock,  and  a  click  denoting  that  it  is  caught.  All 
that  remains  is  to  withdraw  the  tip,  all  the  while  pressing  down  the 
button.  Should  the  foreign  body  be  very  small,  there  will  be  no 
evidence  of  having  brought  it  to  the  magnet,  and  the  instrument 
must  be  withdrawn  and  the  tip  examined.  A  tightly  coapting  wound 
may  tend  to  strip  off  the  foreign  body.  In  that  case  its  lips  will 
have  to  be  parted  with  tiny,  nonmagnetic  retractors  or  a  more 
suitable  tip  substituted.  It  need  hardly  be  stated  that  neither  iron, 
steel,  nor  nickel  instruments  are  admissible  at  the  time  the  magnet 
is  working;  they  must  be  of  brass,  aluminum,  German  silver,  hard 
rubber,  etc.  Those  that  are  not  used  in  conjunction  witji  the  magnet, 
such  as  scissors  and  knives,  may  be  of  the  usual  kind.  Not  succeed- 
ing at  first  in  bringing  out  the  object  sought,  the  tip  may  be  inserted 
again  and  again,  gently  feeling  about  in  the  vicinity,  making  and 
breaking  the  circuit  at  intervals,  and  taking  care  not  to  disturb  the 
vitreous  more  than  is  prudent.  Poking  and  fishing  desperately 
and  deep  are  disastrous  and  inexcusable,  whether  the  foreign  body 
has  been  definitely  located  or  not.  Failing  still,  resort  should  be 
had  to  the  more  powerful  magnet,  rules  for  the  manipulation  of 
which  will  be  given  later.  Having  recovered  the  foreign  body,  the 
site  of  the  operation  is  cleansed,  the  scleral  opening,  if  large  or 
inclined  to  gape,  is  closed   by  a  fine,  absorbable  suture  or  two. 


OPERATING    WITH    GIANT    MAGNET  72 1 

superficially  ])laccd,  he  membranous  opening  sutured  wiih  black 
silk,  and  the  eye  bandaged.  Often  it  is  better  to  omit  stitches  from 
the  sclera.  The  metal  not  having  come  to  light,  it  is  a  question  of 
more  accurate  localization  and  another  magnet  operation,  of 
exenteration,  of  enucleation,  or  of  temporizing,  and  its  decision 
must  be  left  to  the  judgment  of  those  in  charge. 

Supposing  that  the  wound  of  entrance  is  not  available  through 
which  to  extract;  that  the  foreign  body  has  been  located  at  a  distance 
from  it;  or  that  it  has  long  since  healed;  or  thai  penetration  has 
been  by  way  of  the  cornea.  In  any  case  the  scleral  incision  is 
in  order.  This  should  be  as  near  to  the  foreign  body  as  the  situation 
will  allow.  If  making  it  in  an  unfavorable  spot— i.e.,  unfavorable 
to  the  general  good  of  the  eye — can  be  avoided  by  going  in  just  a 
little  to  one  side  of  the  metal;  this  ought  to  be  done.  In  this  manner 
the  recti  muscles,  the  trunks  of  the  vorticose  veins,  the  larger  vessels 
of  the  retina,  etc.,  may  escape  needless  injury.  x-Ml  things  else  being 
equal,  the  best  place  for  the  incision  is  that  recommended  by  Arlt — 
between  the  tendons  of  the  externus  and  inferioris.  The  next  best, 
between  the  latter  and  the  intermis.  The  tissues  overlying  the 
sclera  are  incised,  meridionally,  for  a  distance  greater  than  is  desired 
for  the  deeper  cut.  Retraction  and  stopping  of  the  blood,  as  before. 
The  scleral  incision  is  made  with  a  good  Graefe  knife,  either  by 
puncture  and  counterpuncture  or  by  shallow  perpendicular 
puncture,  for  one  extremity,  and  slight  sawing  to  complete.  It 
should  lie  in  the  middle  of  the  first  opening  and  parallel  with  it. 
Its  length,  to  be  adequate,  will  usually  be  about  one  centimeter. 
The  rest  of  the  operation  is  carried  out  as  described  in  the  preceding 
paragraph. 

Operation  with  the  Giant  Magnet. — The  greatest  authority  on 
the  handling  of  this  instrument  is  its  inventor,  Professor  Haab, 
hence,  most  of  the  points  here  given  are  borrowed  from  him.  The 
surgeon,  assistant,  and  spectators  put  aside  their  watches  to  prevent 
damage  to  their  mechanisms.  The  patient,  with  eye  made  ready, 
sits  on  a  strong,  firm  stool,  facing  the  working  end  of  the  magnet. 
There  are  certain  advantages  in  having  the  instrument  suspended 
in  pivotal  joints.  Great  store  is  set  by  having  the  patient  in  such 
a  position  that  the  head  can  be  freely  moved  by  the  operator  in  every 
direction,  so  that  he  can  give  notice  of  sensations  produced  by  the 
foreign  body,  and  by  having  him  conscious.  JNIoreover,  it  is  ap- 
propriate that  the  patient  be  suffered  to  start  back  when  he  is  hurt 
46 


722 


THE    REMOVAL    OF    FOREIGN   BODIES 


by  any  movement  of  the  forei,u;n  body,  and  get  away  from  too  strong 
a  pull  which  might  do  harm.  This  he  could  not  do  were  he  re- 
cumbent. Therefore,  both  oi)erating-table  and  narcosis  are  dis- 
pensed with.  A  drop  of  cocain  may  be  instilled.  If  the  patient  is 
docile,  neither  speculum  nor  fixation  forceps  are  used,  as  they  would 
simply  be  in  the  way.  Haab  no  longer  employs  a  rheostat,  but 
allows  the  current  to  go  directly  to  the  instrument,  increasing  and 
decreasing  the  force  by  advancing  and  retiring  the  subject's  head, 


I'lr,.  3^4.      Manner  of  using  magncl,  patient  seated. 

and  making  and  breaking  the  current  by  means  of  a  pedal.  There 
can  be  no  objection  to  the  rheostat  provided  it  does  not  materially 
decrease  the  attractive  force,  and  that  there  is  a  switch  between  it  and 
the  magnet.  An  assistant  is  stationed  at  this,  whose  sole  duty  is  to 
throw  it  *'On!"  and  "Off!"  at  these  words  of  command.  Another 
assistant  is  commissioned  to  do  the  illuminating  with  some  form  of 
artificial  light;  another  to  work  the  lever  of  the  rheostat,  if  there  is 
one.     If  the  wound  of  entry  is  still  ])atent,  it  is  usually  chosen  for  the 


OPERATINC,  Willi  c.iAXT  MA(;xi:r  723 

point  of  exit  also,  though  it  may  need  to  be  sh'glilly  extended.  When 
in  the  sclera,  conjunct  i\a  and  other  superjacent  tissues  are  got  out  of 
the  way  by  incisinu;  and  retraclin,L,^  and  the  scleral  oj)cnin,L!;  is 
cleaned  up  by  snii)ping  off  tags  and  shreds  that  extrude.  If  the 
course  of  the  foreign  body  in  the  eye  has  been  traced,  one  endeavors 
to  make  it  retrace  the  same.  By  so  doing,  additional  wounding  of 
the  structures  is  avoided.  The  hair  of  the  subject  is  snugly  covered 
by  a  rubber  cap.  The  operator  grasps  the  head  with  both  liands, 
and  directs  the  patient  to  relax  his  neck,  and  not  to  resist  moli()n>  im- 
parted by  the  hands  (Fig.  374).  The  eye  is  approached  to  the  tip  in 
such  a  way  lliat  the  attractive  force  will  be  exactly  in  line  witli  the  track 
of  the  foreign  body.  If  no  rheostat  is  employed,  the  eye  is  brought 
within  4  or  5  inches  of  the  magnet;  when  the  rheostat  is  used,  the  eye 
is  brought  up  till  its  wound  is  about  in  contact  with  the  tip.  and  the 
aid  at  the  rheostat  is  told  to  turn  on  a  few  amperes — the  milder 
the  draw  with  which  the  foreign  body  comes,  the  better.  If  liere  is 
no  result,  the  current  is  turned  on  or  the  eye  approached  more 
and  more,  till  the  full  capaci  y  of  the  magnet  is  reached.  There 
still  being  no  result,  one  proceeds  to  jerk  at  the  foreign  body  by 
making  and  breaking  the  current  in  quick  succession;  and,  failing 
in  this,  sidewise  pulls  are  given  to  loosen  the  metal.  Should  the 
patient  wince  or  speak  of  pain  in  the  eye,  the  pull  is  at  once  changed 
to  the  original  direction.  When  the  foreign  body  ])rcsents  at  the 
opening  its  delivery  may  have  to  be  helped  by  separating  tlie  lii)s 
or  with  the  forceps.  A  sharp  lookout  is  kept  for  the  ap])earance 
of  the  foreign  body,  especially  for  a  very  minute  one  that  may  have 
attached  itself  to  the  tip  of  the  magnet,  so  as  not  to  drop  and  lose 
it  by  breaking  the  circuit.  All  these  procedures  having  proved 
fruitless,  one  is  not  justified  in  giving  up  completely,  but  should, 
after  a  wait  of  some  hours  or  a  day,  make  a  second  effort;  even 
after  that,  a  third.  Haab  relates  instances  where  he  made  trials 
on  several  days  in  succession,  then  succeeded.  Between  whiles, 
a  great  deal  might  be  gained  by  localization. 

If  the  scleral  route  is  decided  upon  as  the  way  out  for  the  foreign 
body,  irrespective  of  the  preexistence  of  a  scleral  wound,  the  steps 
are  about  the  same  as  those  detailed  for  the  small  magnet,  except 
that  no  sort  of  extension  point  is  inserted  at  the  openin<^.  With  j)roper 
localization  and  a  ])owerful  magnet,  such  as  the  giant  is  supposed  to 
be,  contact  of  the  tip  with  the  outer  lips  of  the  incision  should  be  the 
limit. 


724  THE    REMOVAL    OF    FOREIGN   BODIES 

An  exception  would  be  in  case  the  foreign  body  were  too  firmly 
held  by  the  tissues  to  be  moved  by  the  magnet.  In  such  instances 
a  Graefe  squint  hook  makes  a  most  serviceable  auxiliary  to  the  giant 
magnet.  Placed  in  contact  with  the  tip  of  the  magent,  it  can  be 
easily  slid  in  and  out  at  the  scleral  opening  and  the  metal  "fished" 
for  in  this  way. 

Drawing  the  Foreign  Body  from  the  Vitreous  into  the 
Anterior  Chamber. — When  no  scleral  opening  exists,  and  the  for- 
eign body  is  not  too  large,  the  stronger  partisans  of  the  giant  magnet 
advocate  this,  then  extracting  through  a  corneal  incision  rather 
than  removal  directly  from  the  Aitreous  by  means  of  a  scleral  in- 
cision. Here,  if  the  foreign  body  is  in  the  posterior  segment,  the 
tip  of  the  magnet  is  applied  to  the  summit  of  the  cornea,  so  that,  in 
coming  forward,  it  will  not  engage  in  the  ciliary  body.  A  piece  of 
metal  once  caught  in  the  soft  corrugations  there,  either  primarily  or 
secondarily — especially  if  it  is  sharp  and  angular — is  most  dilRcult 
to  extricate.  If  the  lens  is  already  much  wounded  or  cataractous, 
the  attraction  may  be  kept  up,  as  begun,  until  the  foreign  body  is 
seen  to  enter  the  anterior  chamber.  If,  on  the  other  hand,  the 
crystalline  seems  normal  or  but  little  injured,  as  soon  as  there  has 
been  any  evidence  of  advancement  on  the  part  of  the  foreign  body 
or  it  has  come  up  behind  the  back  surface  of  the  lens,  the  direction 
of  the  attraction  is  shifted  to  a  point  near  the  limbus  so  as  to  cause 
the  metal  to  travel  around  by  the  zonule.  Now,  one  must  watch 
closely  for  any  bulging  forward  of  the  iris  produced  by  the  foreign 
body.  The  impact  against  this  sensitive  membrane  is  often  first 
made  known  by  a  sudden  move  by  the  patient.  The  current  is  in- 
stantly shut  off  and  tip  changed  to  the  opposite  side,  in  order  to 
make  the  foreign  body  pass  through  the  pupil.  To  have  the  latter 
dilated  facilitates  this  step.  If  any  special  difficulties  seem  to  lie 
in  the  way  of  getting  the  foreign  body  readily  through  the  pupil,  it 
were  better  to  make  an  iridectomy  just  over  the  point  where  the 
foreign  body  lies  in  the  posterior  chamber.  Having  been  brought 
into  the  anterior  chamber  the  piece  of  metal  is  finally  drawn  into  the 
lower  iridic  angle  to  await  its  extraction  according  to  the  rules 
already  given.  It  is  of  the  greatest  importance  that  every  precaution 
be  taken  to  prevent  the  patient  from  squeezing  the  globe  during  the 
subsequent  steps  of  the  operation;  for  this  would  be  likely  to  result 
in  at  least  two  most  unfoiiuiiale  accidcMits,  \iz.,  lirst  the  forcing 
of  \  itreous  u])  througli  the  track  or  bore  made  bv  the  foreign  bodv, 


LOOSENING    WITH    MAGNET  725 

and,  second,  a  prolapse  of  the  iris.  Under  these  conditions  the  iris 
is  difficult  or  impossible  of  replacement,  making  an  iridectomy 
necessary.  All  this  tends  to  vitiate  the  ultimate  result.  For  these 
reasons  the  eye  should  be  thoroughly  anesthetized  by  cocain  before 
making  the  corneal  incision  that  is  to  admit  the  tip  of  the  hand- 
magnet.  Moreover,  the  lids  should  be  held  apart  by  means  of  non- 
magnetic retractors,  in  the  hands  of  one  who  knows  how.  Fixation 
of  the  globe,  too,  is  better  dispensed  with  whenever  the  patient  is 
reasonably  well  behaved. 

Loosening. — When  the  foreign  body  is  fast  in  any  of  the  tunics 
of  the  globe  or  is  densely  encapsuled,  the  chances  of  getting  it  with 
even  the  most  powerful  magnet  are  greatly  lessened.  A  valuable 
office  filled  by  the  big  magnet  in  these  cases  is  the  loosening  of  the 
metal.  When  possible,  its  exact  location  is  ascertained  beforehand. 
The  patient  is  placed  on  a  stool  in  front  of  the  magnet,  and  the  tip 
is  applied  to  the  globe  or  approached  close  to  it,  in  the  immediate 
vicinity  of  the  foreign  body,  in  such  a  way  as  to  pull  it  sidewise. 
Every  means  must  be  used  to  obtain  the  full  strength  of  the  magnet. 
And  it  may  be  necessary  to  go  all  around  the  foreign  body,  pulling 
from  every  point;  shutting  the  current  off  and  on  in  quick  succession 
now  and  again.  The  patient  is  instructed  to  be  on  the  alert  for  any 
sensation  indicative  of  movement  on  the  part  of  the  foreign  body, 
such  as  a  jar  or  vibration,  a  flash  of  light,  or  a  pain  in  the  eye,  and 
to  tell  of  it  at  once.  A  change  having  been  felt,  before  the  foreign 
body  could  be  intelligently  extracted  it  might  be  necessary  to  relocate 
it.  If  this  could  be  done  with  the  ophthalmoscope,  so  much  the 
better.  Certainly,  before  thinking  of  a  scleral  incision  through 
which  to  extract,  localization  should  be  essential.  Were  the 
foreign  body  situated  in  the  ciliary  body  or  in  the  root  of  the  iris, 
to  draw  it  forward  might  only  make  matters  worse,  and  to  cut  down 
upon  it  under  these  conditions  at  once  would  hardly  be  proper. 
The  preferable  way  would  be  to  draw  it  j&rst  backward,  and,  if 
possible,  slightly  inward,  that  is,  with  respect  to  the  center  of  the 
vitreous.  When  practicable,  this  should  be  done  on  that  side  of 
the  sclera  adjacent  to  the  foreign  body.  Having  moved  it,  relocation 
or  not,  and  removal  according  to  one  of  the  approved  methods. 
It  is  well,  always  to  remember  that  success  depends  in  great  measure 
upon  localization.  If,  on  the  contrary,  the  foreign  body  refused 
to  budge,  then  one  need  not  hesitate  to  make  incision  over  it  and 
to  attempt  its  extraction  with  one  or  both  of  the  magnets  and,  if 


726  THE    REMOVAL    OF    FOREIGN    BODIES 

need  be,  with  the  aid  of  probe  and  forceps.  The  fact  that  the  cut 
would  He  in  the  ciHary  zone  need  no  longer  be  a  bar. 

Relative  Merits  of  Small  and  Large  Magnets.— To  a  consider- 
able extent  the  impression  seems  to  prevail  that,  as  regards  this 
subject,  ophthalmic  surgeons  are  divided  into  two  camps — one  led 
by  Hirschberg  and  the  other  by  Haab.  As  a  matter  of  fact,  there 
are  many  who  are  more  uncompromising  in  this  affair  than  is  either 
of  the  gentlemen  just  named.  Hirschberg  not  only  uses  the  large 
magnet  when  occasion  requires  it,  but  he  has  actually  had  constructed 
a  larger  one  than  that  of  Haab.  And  he  of  Zurich?  Well,  he 
often  employs  the  hand-magnet  in  connection  with  the  anterior 
chamber,  and  has  been  known  to  do  so  for  foreign  bodies  behind 
the  iris.  To  quote  his  own  words:  "When  shall  the  small  magnet 
be  used?  Answer:  Within  the  bounds  of  the  vitreous  as  little  as 
possible;  within  those  of  the  anterior  chamber  as  you  will."  Un- 
questionably, each  has  its  advantages  and  each  its  limitations,  if 
not  its  drawbacks,  and  both  are  absolutely  indispensable  in  this 
kind  of  work.  None  have  better  proven  their  worth  than  their 
illustrious  inventors  themselves — Hirschberg  in  more  than  450 
instances,  Haab  in  more  than  500. 

It  is  certain  that  the  small  magnet  is  easily  portable,  that  it  is  more 
manageable,  and  now,  with  the  more  powerful  model,  reinforced  to 
the  utmost,  a  lifting  capacity  can  be  obtained  that  almost  makes 
it  equal  to  some  of  the  so-called  "giants."  In  a  case  of  recent 
foreign  body  in  the  vitreous  the  hand-magnet  has  been  able  to  draw 
the  metal  through  the  lens  and  into  the  anterior  chamber;  and  to 
extract  one  through  a  scleral  opening  without  letting  the  tip  come 
in  contact  with  the  globe.  Again,  there  have  been  cases  where 
neither  the  sideroscope  nor  the  giant  magnet  got  any  response  from 
a  foreign  body  in  the  vitreous,  yet  it  was  extracted  by  the  small 
magnet  through  a  scleral  incision.  It  may  be  pretty  safely  asserted 
that  most  authorities  are  decidedly  against  drawing  the  foreign 
bodies  from  the  vitreous  into  the  anterior  chamber  unless  the  wound 
of  entrance  has  been  through  the  cornea.  And  Mayweg,  who  is 
recognized  as  an  imjjarlial  as  well  as  an  able  critic,  has  compiled 
careful  statistics  tending  to  prove  that  the  scleral  route,  with  incision, 
gives  the  best  results  e\en  with  the  giant  magnet.  It  would  seem, 
then,  that  the  fault  of  the  scleral  route  did  not  lie  with  the  incision. 
With  what  is  it?  I'robably  insuHlcient  localization,  disregard  of 
the  xitreous,  etc. 


CHOICE    OF    MAGNET  727 

The  <i;rcal  distinctive  feature  of  the  i^iant  ma,^net  is  that  it  hiis  a 
drawing  ])0\ver  far  in  excess  of  that  of  the  hand  magnet,  thus  j^ermit- 
ting  extraction  from  without;  and  not,  as  has  been  so  generally 
asserted,  the  fact  tliat  it  does  not  necessitate ///r/Z/r;-  ()])L'ning  of  the 
globe.  This  same  power  has  led,  in  some  quarters,  lo  a  contemj)t 
for  localization  or  for  diagnosis  as  to  the  mere  presence  of  a  foreign 
body,  the  claim  being  that  if  one  is  present,  there  is  a  good  chance  of 
bringing  it  out — if  not,  no  harm  is  done.  Hirschberg  declares  that 
it  is  precisely  that  enormous  strength  tliat  constitutes  the  danger, 
and  condemns  its  employment  for  diagnostic  jiurposes.  He  denies 
its  elTiciency  in  this  capacity,  and  says  that  he  has  seen  more  than 
a  dozen  cases  in  which  such  trials  proved  negative;  nevertheless,  a 
piece  of  metal  was  located  and  extracted  through  a  scleral  incision 
in  each.  Hirschberg  considers  the  large  magnet  useful  in  loosening 
foreign  bodies  that  are  held  fast,  and  particularly  so  in  removing 
small  ones  that  lie  in  the  remote  parts  of  the  ^•itreous  chamber, 
as  also  for  cases  of  long  standing.  In  recent  cases  Haab  ^•ery  justly 
rates  the  importance  of  localization  as  secondary  to  that  of  quick 
extraction,  but  insists  upon  the  value  of  knowing  the  situation  of 
the  wound,  and  the  track  inside  of  the  eye.  When  the  injured  eye 
is  on  the  verge  of  panophthalmitis,  every  minute  counts. 

After  all,  it  seems  to  be  pretty  generally  conceded  or  implied 
that  localization,  scleral  incision  (if  no  open  wound  already  exists), 
and  the  use  of  the  large  magnet  constitute  the  most  eligible  procedures 
for  most  cases  of  iron  or  steel  in  the  vitreous  chamber.  Hirschberg's 
"Three  Principal  Causes  of  the  Insuccess  of  Alagnet  Operations" 
read  almost  like  a  defense  of  the  large  magnet  and  an  accusation  of 
the  small.     They  are: 

1.  Loss  of  the  eye  from  inliammatory  processes  after  successful 
extraction  of  the  foreign  body. 

2.  Insufficient  traction  power  in  the  magnet. 

3.  Too  lirm  an  anchorage  of  the  metal  in  its  bed. 
He  might  have  added : 

4.  Insufficient  measures  of  localization. 

It  must  be  admitted,  however,  that  in  many  instances  the  drawing 
of  the  metal  from  the  vitreous  into  the  anterior  chamber  and  its 
removal  thence  by  means  of  the  hand  magnet  through  an  appro- 
priate incision  constitutes  a  most  elegant  and  satisfactory  operation. 


INDEX. 


Abadie's  irito-cctomy,  442 
Abaissement  of  cataract,  579 
Abrasion  of  the  cornea,  383 
Accidents    after   cataract    extraction, 

522-534 
after  cyclodialysis,  425 
after  tenotomy,  165 
in  cataract  extraction,  522 
in  discission,  584 
in  enucleation,  491,  493 
in  iridectomy  for  glaucoma,  471, 

477 

in  trephining  of  the  sclera,  646 
Actual  cautery,  386 

application  of,  387 

in  corneal  ulcer,  388 
Adams'  operation  for  ectropion,  286 
Adhesive  plaster  dressing,  20 
Adults,    young,    linear    extraction   of 

cataract  in,  559 
Advancement   of   tendon  for   squint, 
169,185,201-206.     (Seealso 
Squint.) 

age  limits  for,  201 

choice  of  method,  202 

of  extraocular  muscles,  169 

general  considerations  on,  201-206 

of  levator  tendon,  238 

for  secondary  squint,  200 

of  Tenon's  capsule,  185 
After-cataract,  589 

after  treatment  of,  595 

arrachement  for,  593 

causes,  590 

dilaceration  for,  594 

discission  for,  591 

division  with  scissors,  596 

extraction  of,  594 

posterior  discission  for,  593 

technic  of  operation  for,  591,  567 

time  to  operate,  590 
Age  limit  for  cataract  operations,  497 

for  discission  of  soft  cataract,  583 

for  enucleation,  496 

for  muscle  operations,  201 
Agnew's  blunt  hook  operation,  562 

eye-douche,  36 

lacrimal  knife,  61 

canthoplasty,  218 

methods  for  anterior  synechia,  446 
of  irito-ectomy,  442 


Agnew's  operation  for  enucleation,  497 

for  peritomy,  360,  361 
Air     bubbles     in    anterior    chamber, 

525 
Amputation  of  globe,  anterior,  436 

posterior,  436 
Anel's  syringe,  12 
Anesthesia,  69 

in  enucleation,  496 
in  extraction,  504 
in  iridectomy,  456 
general,  12 
infiltration,  11 
local,  10 
Anagnostakis-Hotz  operation  for  en- 
tropion, 260 
Angelucci's    method    of    fixation    in 
cataract  operations,  551,  564, 
565.  596 
Ankyloblepheron,  Langier's  operation 

for,  333 
Anterior     capsule,     arrachement     of, 
556,  568 
opening  of,  in  extraction,  509, 
526,  554-557 
chamber,  blood  in,  390,  477,  525, 
546 
foreign  bodies  in,  688 
irrigation  of,  514,  557 
pus  in,  390 
lens  capsule.     (See  Anterior  Cap- 
sule.) 
sclerotomy,  417 
Beard's,  635 
Herbert's,  628 
De  Weckcr's,  417 
indications  for,  419 
Panas',  418 
Van  Lint's,  634 
Vicenti's,  418 
staphyloma,     Critchett's     opera- 
tion for,  401 
De  Wecker's  operation  for,  402 
history    of    surgery    for,    401, 

402 
Knapp's  operation  for,  401 
synechia,  operations  for,  426,  443- 

447 
Applications  of  heat,  cold,  etc.,  42-46 
Applicators,  32 
Applying  caustics,  41 
Aqueous    humor,    escape    of,    during 

corneal  incision,  523 


729 


730 


INDEX 


Argyll-Robertson's     "strap"     opera- 
tion, 292 
suture  for  ectropion,  284 
Arlt.     (See  Von  Arlt.) 
Arrachement  of  capsule  after  cataract, 
593 
in  extraction,  556 
of  iris  in  iridectomy,  470 
Artificial  leech,  51 

ripening  operations,  597 
by  discission,  598 
by  hot  air,  600 
by  incision  and  massage,  598 
by  intracapsular  injections,  599 
vitreous  body,  435 
Asepsis,  I 

Aspiration  of  cataract,  579 
Atropin    dermatitis    after   extraction, 
546 
before  extraction,  502,  534 
before  iridectomy,  455 
Autoplasty,  by  cutaneous  grafts,  319, 
337 
French  method,  296 
Indian  method,  305 
Italian  method,  326 

B 

Bader's  knives,  63 

Ball,  introduction  of  glass  or  gold,  in 

eye,  435 
Balance,  Priestly  Smith's,  for  testing 

knives,  119 
Bandages,  14-20 
binocular,  19 
monocular,  17 
Bandaging,  15 

effects  of  tight,  543 
Barr's  fixation  forceps,  87 
Beard's  cystotome,  64 

anterior  sclerotomy,  635 
exenteration     knife-spatula,     73, 

432 
fixation  forceps,  87 
hooks  for  closing  wounds,  382 
knife,  60 

for  discission,  441,  585,  587 
lacrimal  sounds,  122 
operation  for  advancement,  180 
for  ant.  synechia,  445 
for  ectropion,  288 
for  entropion,  266,  273 
for  exenteration,  432 
for  plerygium,  349 
for  ptosis,  244 
for  shortening,  191 
for   total   symblepharon,    343- 

345 
speculum,  107,  197 
trephination,  648,  650 
trephine,  647 
Beer's  knife,  61 

Beer-Wccker    operation    for    corneal 
stajihyloma,  402 


Berger's  operation  for  epicanthus,  228 

restoration  of  upper  lid,  327 
Bishop's  operation  for  ptosis,  234 
Bistouries,  67 
Bjerrum's  sclerotomy,  631 
Blasius'  method  of  blepharoplasty,  307 
Blepharopexy,  235 
Blepharoplasty,  292 

by  cutaneous  grafts,  319 
by  sliding  flaps,  288,  309 
Fricke's  operation,  306 
French  method,  296 
Indian  method,  305 
Italian  method,  326 
varieties  of,  295 
Blepharoptosis  or  ptosis,  230 
Blepharostats,  107-109 
Blood  in  anterior  chamber,  390,  477, 
525,  546 
,     lettmg,  49-52 
local,  50 

by  venesection,  49 
Blue  vision  after  extraction,  547 
Blunt  hook,  67,  562 
Bonnet's  enucleation  operation,  478 
Bowman's    double    needle   operation, 
594 
operation   of   slitting   the   canal- 
iculus, 131 
probes,  121 
stop  needle,  65 
trephine,  640 
Bridge  coloboma,  451,  474 
Brossage  for  trachoma,  364 
Bruns'  advancement,  188 
Brushes,  32 
Buedinger's  restoration  of  lower  lid, 

318 
Bulging  cicatrix  after  cataract  extrac- 
tion, 538 
BuUer's  ligation  of  canaliculus,  139 
Burnett's  iridectomy,  466 
Butler's   extirpation  of   lacrimal   sac, 

,     149 
Burow  s    method    of    blepharoplastj'-, 
302 


Canaliculi,  ligation  of,  136 

slitting  of,  131 
Canaliculus  knife,  Agnew's,  61 

Weber's,  61 
Canthoplasty,  217-220 
Capsular  advancement,  185 
Capsule,  forceps,  94,  556 

advancement  of  Tenon's,  185 

opening  of,  509,  526,  554-557 
Capsulotomy    in    extraction    of    cat- 
aract, 509,  526,  554-557 
Carter,  Brundenell,  iridectomy,  466 
Cataract,  abaisscment  for,  579 

accidents  during  extraction,  522 
after  extraction,  534 


INDEX 


731 


Cataract,  adherent,  560 

after-    (see   also    After-cataract), 

589   . 
age  of  subject,  497 
among  glass-blowers,  600 
artificial  ripening  of,  597 

by  discission,  598 

by  hot  air,  606 

by  incision  and  massage,  59S 

by  intracapsular  injections,  599 
aspiration  or  suction,  579 
astigmatism  after,  576 
capsular,  extraction  of,  562,  568 
capsulo-lenticular,  562,  589 
collapse  of  cornea  in,  531 
complicated,  559 
condition  of  eye  in  extraction,  497 

of  lens  in  extraction,  499 

of  patient  in  extraction,  497 
congenital,  562 
couching  for,  579 
counter-puncture,  507 
depression  for,  579 
diabetic,  549 
diplopia  in,  500 
discission  for,  566,  582 
dislocated,  564,  566 
displacement  for,  579 
"don'ts"  in  extraction  of,  515 
expression  of,  510,  557 
expulsive  hemorrhage  in  extrac- 
tion of,  532 
extraction    of    senile.      (See    Ex- 
traction of  Cataract.) 

of  membranous,  594 
incision  for  extraction,  507,  524, 

552,  606-  622 
iridectomy  in,  547,  550 
knife,  62,  606-610,  612 

Graefe,  62,  610 
lamellar  (see  also  Cataract,  zonu- 
lar), 459 
luxated,  564,  566 
membranous,  589,  594 
Morgagnian,  564 
needle  operation  for,  566 
nucleus  after  discission,  528 
operations  for,  497 
reclination  of,  579 
ripening  of,  artificial,  597 
secondary.      (See  After-cataract.) 
shrunken,  560 
simple,  extraction  of,  505 
soft,  extraction  of,  559 
suction  method  for,  579 
tremulous,  564 
urine  in,  497 
zonular,  459 
Caustics,  41 
Cautery,  actual,  386 
corneal,  385,  396-9 
electric,  386 

galvano-puncture,  394,  396 
Paquelin,  386 
thermic,  386 


C\llulitis,  orljital  incisions  for,  679 
Criialazion,  operation  for,  213,  217 
Chandler's     iridectomy     in     cataract 

extraction,  535 
Changing  of  dressings,  28,  520 
Check  ligaments,  ojjeration  upon,  194 
Chemosis,    filtration,    after    cataract 

extraction,  524 
Chloroform,  as  anesthetic,  12 
Choroid,    detachment    of,    in    cyclo- 
dialysis, 426 

hemorrhage  from,  532 
Choroidal  hemorrhage,  532 
Cicatricial  ectropion,  280 
operation  for,  280 

entropion,  253,  280 
dressing  for,  272 
Cicatristomy  of  De  Wecker,  418 
Cicatrix  bulging  after  cataract  extrac- 
tion, 538 
Cilia.      (See  Eye  Lashes.) 

forceps,  95,  209 
Cilium  forceps,  95,  209 
Circumcising  cornea,  360,  480 
Clamps,  95 

Clark's  tendon  tucker,  188 
Cleansing  the  eye,  28 
Cocain,  10,  504 
Cold  applications,  42-46 
Collapse  of  cornea  during  cataract  ex- 
traction, 531 
Coloboma,  468-471 

in  extraction,  468-470 

in  glaucoma,  469 

in  optical  iridectomy,  449 
of  upper  lid,  302 
Combined  excision  for  trachoma,  371 

extraction  of  cataract,  547 
Condition  of  eye  for  extraction,  497 

of  iris  and  pupil  for   extraction, 
489 
Congenital  ptosis,  230,  250 

cataract,  discission  in,  582 
Conical  cornea,  operations  for,  395-400 
Conjunctiva,  operations  on,  329 
Conjunctival  fla]),  508 

in  trephining  tlie  sclera,  650 

keratoplasty,  404-408 
Corelysis,  434 

Wenzel's,  434 
Cornea,  abrasion  of,  383 

circumcising,  360 

cautery  of,  385,  396-399 

collapse  of,  in  extraction,  531 

conical,  395 

foreign  bodies  in,  379-3^3 

galvano-puncture  of,  394,  396 

incision  of,  389 

massage  of,  393 

operations  on,  379 

paracentesis  of,  389 

splitting  of,  471,  524 

staphyloma  of,  400 

tatooing  of,  413-416 

ulcers  of,  392 


732 


Corneal  grafting,  404,  409-413 

incision    in    cataract    extraction, 

507,  524,  552,  606-622 
scars,  removal  of,  384 
staphyloma,  operations  for,  400 
suture  in  extraction,  553 
transplantation,  409-413 
partial,  409 
total,  409 
trephine,  411 
Von  Hippel's,  411 
Cortical  substance,   removal  of,   512, 

538,  557 
Coremorphosis,  449 
Cotton,  13 

Couching  cataract,  579-582 
Counter-puncture,  507 
Critchett's    advancement    operation, 
170 
exenteration  of  globe,  431 
extraction  of  cataract,  608 
iridesis,  451 

operation     for     anterior     staph- 
yloma, 401 
sphincterectomy,  452 
tenotomy,  162 
Curet,  Terson's,  136 
Curets,  73 
Cutaneous    grafts    in    operation    for 

ectropion,  319,  337 
Cyanid  of  mercury  injections,  48 
Cyclodialysis  (Heine),  422 
complications  of,  425 
contraindications  of,  425 
indications  for,  425 
indications  for,  425 
results  of,  426 
Cyst,  Meibomian,  213-220 

of   anterior   chamber,    implanta- 
tion, 426 
Cystoid  cicatrix,  403,  404 

after  cataract  extraction,  538 
after   iridectomy    for    glaucoma, 

453,  625 
operations  for,  393,  403 
Cystotomes,  63,  65 
Beard's,  64 
Graefe's,  64 
Knapp's,  64 
Cystotomy,  509,  526,  554-557 
Czermak's  subconjunctival  extraction, 
552 
operation  for  symblepharon,  338 
treatment  of  entropion  from  bone 
lesions,  317 


Dacryocysto-rhinostomy,  149 
Da  Gama  Pinto's  posterior  discission, 
^      .    ,    593 

Daviel  s  operation  for  cataract,  605 
Da  Grandemont's  operation  for  ptosis, 
241 


Delgado's     intracapsular     extraction, 

569 
Dementia  after  extraction,  545 
Denonvilliers'   operation  for   restora- 
tion of  lower  lid,  307 
Dermic  grafts   in  operations  for  en- 
tropion, 319 
preparation  of,  321 
Dermo-epidermic  grafts,  323 
Descemet's    membrane,     detachment 
of,  in  cyclodialysis,  425 
in  corneal  cautery,  388 
Desmarres'  elevator,  74 

operation  for  pterygium,  350,  355 
Detachment   of   conjunctiva   in   enu- 
cleation, 480 
of      Descemet's     membrane     in 

cyclodialysis,  425 
of    retina   following    prolapse    of 

vitreous,  529 
of    retina,    posterior    sclerotomy 
for,  400 
importance  of  ophthalmoscope 

in,  668 
operations  for,  660 
Bull's,  662 
Deutschmann's,  663 
Elschnig's,  662 
Mueller's,  427 
trephining  sclera  for,  426,  641 
Deutschman's  operations  for  detached 

retina,  663 
De  Wecker's  advancement  of  Tenon's 
capsule,  185 
Knapp's  modification  of,  185 
anterior  sclerotomy,  417 
combined  sclerotomy,  419 
enucleation,  484 

for  staphyloma,  402 
extraction,  612 

knife,  612 
iridotomy,  438 
operation  for  ptosis,  232 
pince-ciseaux,  85 
sclerotomy,  anterior,  417 
tattooage  of  the  cornea,  413 
tendon  advancerrient,  174 
De  Wenzel's  cataract  extraction,  562, 
606 
knife,  606 
incision  for  extraction,  562,  606 
Dianoux's    operation    for    entropion, 

261 
Dieffenbach's    method    of    blepharo- 
plasty,  289,  296,  297,  299 
advancement,  169 
Dilaceration    of    secondary    cataract, 

594 

Dilatation  of  punctum,  120 

Discission,  566,  582 

accidents  incident  to,  584,  588 
age  limit  for,  583 
artificial  ripening  by,  597 
Bowman's  double  needle,  594 
Bull's,  for  detachment,  663 


INDEX 


733 


Discission,  knife  for,  60,  441,  585,  587 
point  of  entrance  for  knife,   591 
tcchnic  of,  585,  591 
with  scissors,  596 
two  needles,  594 
Dislocation  of  lens  in  extraction,  sC>4, 

566 
Dissector,  blunt,  66 
Divergence   secondary   to   tenotomy, 

166,  200 
Division  of  after-cataract  by  scissors, 
.596 
optic  nerve,  482,  489 
muscles  in  enucleation,  479,  489 
Double-transplantation  operation  for 

pterygium,  350,  355 
Douches,  36 
Douching,  38 

Dransart's  operation  for  ptosis,  232 
Dressings,  13 

for  ectropion,  272 
for  entropion,  272 
for  excision  of  lacrimal  gland,  157 

sac,  149 
for  extraction,  518-520 
after  ,'operation  in  linear  extrac- 
tion of  cataract,  518 
Droppers,  34 


Ectropion  and  blepharoplasty,  280 
general  remarks,  280 

Argyll-Robertson's     suture     for, 
284 

cicatricial,  281,  292 

cutaneous  grafts  in  operation  for, 
319 

Fricke's  operation  for,  306 

from     bone     lesions     of     orbit, 
Tripier's  operation  for,  317 
Czermak's  treatment  of,  317 

Fukala's  suture  for,  285 

mechanical,  281 
measures  for,  281 

mucous,  282 

of  lower  lid,  281 

operations  for,  281 

paralytic,  281 

senile,  281 

Snellen's  suture  for,  282 

spastic,  280 
Electrolysis  of  lacrimal  canal,  137 

of  pterygium,  356 

for  trichiasis,  212 
Electromagnet,  693 
Elephantiasis  of  eyelid,  230 
Elevator,  Desmarre's,  74 

Fisher's,  551 
Elliot's  trephination,  642-646 

complications  and  dangers  of,  657 
Elschnig's  advancement,  178 

peripheral  incision  of  iris,  536 

sclerectomy  for  detachment,  662 


ICiioplitlialmos     after     advancement, 

201 
Entropion,  253 

and  trichiasis,  conclusions,  273 

cicatricial,  258,  280 

choice  of  marginal  graft,  273 

functional,  253 

lower  lid,  operations  for,  278,  280 

organic,  operations  for,  258-280 

senile,  operation  for,  253 

spastic,  operations  for,  253 

suture  methods  for,  255 

ulcer  of  cornea  after  operations 
for,  277 
Enucleation,  478 

accidents,  immediate,  491 
consecutive,  493 

Agnew's  method,  479 

Bonnet's  method,  478 

detachment    of    conjunctiva    in, 

459 

division   of   straight   muscles   in, 
463,  469,  489 

general  considerations,  488 

history  of,  478 

indications  for,  494,  496 

in  panoophthalmitis,  495 

in  sympathetic  ophthalmitis,  494 

hemorrhage  after,  491 

Menacho's  method,  483 

modifications  of,  483 

perforation  of  sclera  in,  491 

resection  of  optic  nerve  in,  490 

scissors,  81,  87,  490 

severance  of  optic  nerve  in,  489 

suture  after,  491 

sympathetic  inflammation  after, 
484 

technic  of,  479,  488-491 

Vienna  metliod  for,  479 

Von  Arlt's  method  for,  479,  483 
E])icanthus,  operations  for,  226 
E])idermic  grafts,  323,  338 
Epilation  of  eyelashes,  209,  212 

forceps,  95,  211 
Eserin  after  simple  extraction,  534 
Esotropia,  158 
Ether,  12 
Everbusch's  operation  for  ptosis,  238 

retractor,  146 

skin  grafts,  323 
Evcrsion  of  eyelid,  207 

of  lacrimal  puncta,  134 

of  puncta,  internal  tarsorrliaphy 
for,  222 
Evisceration,  430 

of  eyeball,  430 

sympathetic  inflammation  after, 

465 
Ewing's  operation  for  entropion,  276 
Examination  in  cases  of  foreign  body 

in  eyeball,  627 
Excision  of  tarsus,  225,  370-377 
combined,  for  trachoma,  371 
for  pterygium,  340 


734 


IXDEX 


576 


53 


Excision  of  skin  for  entropion,  257 
Exenteration  of  orbital   cavity,   683, 
686 
of  sclera  or  globe,  430 
Beard's,  432 

knife  spatula  for,  73,  432 
De  Wecker's,  432 
Gifford's,  432 
indications  for,  434 
sympathetic    i  n  fl  a  m  m  a  t  i  o  n 
'  after,  485 
Von  Graefe's,  431 
Exophthalmos     following     tenotomy, 

166 
Exostosis  of  orbit,  680 
Exotropia,  158 
Expression  for  trachoma,  365 

of  cataract,  510,  557 
Expressor,  Kuhnt's,  366 
Expulsive  hemorrhage  from  choroid, 
532,  576 
in  cataract  extraction,  53: 
Exsection  of  tarsus,  225,  370-377 
External  tarsorrhaphy,  221 
Extirpation  of  lacrimal  gland, 
of  sac,  138-149 

Harrison  Butler's,  149 
of  tarsus,  224 
Extraction  of  cataract,  497 

accidents  immediate,  522 
consecutive,  534 
after  treatment,  519 
age  of  patient,  497 
Angelucci's    fixation    in,     551, 

564-5,  596 
anesthesia  in,  504 
arrachement  of  capsule  in,  556 
atropin  poisoning  after,  546 
blood  in  anterior  chamber,  525 
blue  vision  after,  547 
blunt  hook,  562,  563 
capsulotom}'  in,  509,  554-7 

preliminary,  569 
chemosis  filtration,  542 
choice  of  operation,  547 
clearing  out  lens  remains,  512, 

538,  557 
closure  of  wound,  522 
collapse  of  cornea  in,  531 
combined,  547 

indications  for,  543 
condition  of  eye,  497,  498 
of  lens,  499 
of  patient,  497 
conjunctival  flap,  508 
bridge,  552 
suture,  554 
corneal  suture  in,  553 
cortical  matter  after,  512,  538, 

557 
counter-puncture,  507 
cyclitis  after,  539 
cystoid  cicatrix,  538 
cystotomy  in,  509,  526,  554-7 

preliminary,  569 


Extraction  of  cataract,  David's,  605 
delayed  healing  after,  543 
delivery  of  lens  in,  510,  557 
dementia  after,  545 
"don'ts"  in,  515 
double,  500 
dressing  after,  518-520 

first,  518 
entropion  after,  546 
erythropsia  after,  547 
expression  of  lens  in,  510,  557 
expulsive     hemorrhage     after, 

532 
filtration  chemosis,  542 
first  dressing  after,  518,  520 
fixation  of  globe  in,  506,  552, 

564-5,  596 
gaping  of  wound  after,  533 
general  considerations,  497 
glaucoma  after,  544,  566 
healing  after,  533,  543 
hemorrhage  after,  525,  532,  546 
history  of,  601-615 
holding  the  lids  apart  in,  550 
in  capsule,  567 

accidents  and  complications, 
573-576 
incision  for,  507,  524,  552,  606- 

622 
Indian  method,  570 
indications  for,  528 
infection  after,  540 
insanity  after,  555 
intracapsular,  567 

accidents  and  complications, 
573-576 
intraocular   hemorrhage   after, 

532 
iridectomy   in,    535,   548,    549, 

550,  561 
iridocyclitis  after,  539 
iritis  after,  539 
irrigation  of  anterior  chamber 

after,  514,  557 
keratitis  after,  544 
keratome  in,  559 
kianopsia  aftef,  547 
lavage  after,  514,  557 
linear,  559 

mydriasis  in,  502,  534 
of  adherent  cataract,  De  Wen- 

zel's,  562 
])eripheral   incision   of   iris   in, 

536 
l)osition  of  patient,  503 
pri'liminary  iridectomy  in,  505 
])n'paration  of  eye  for,  502 

of  patient,  501 
jjrolapse  of  iris  after,  531,  534, 
538 

of  vitreous  after,  529,  574 
puncture     and     counter-punc- 
ture, 507 
red  vision  after,  547 
relative  merits  of  methods,  547 


INDEX 


735 


Extraction    of    cataract,    removal   of 
cortex,  512 
retroversion  of  iris  after,  539 
rigidity  of  pupil  in,  527 
rupture  of  capsule,  574 
rupture  of  zonule,  51 1 
senile  entropion  after,  546 
simple,  505 

technic  of,  505,  550,  571 
or  combined  ?,  540 
sinking  of  lens  into  vitreous,  528 
slow  closure  of  wound,  533 
spastic  entropion  after,  546 
splitting   cornea   in,    S24,    527, 

619 
striped  keratitis  after,  544 
subconjunctival,  552 
suppuration  after,  540 
suture  of  conjunctiva  in,  524 

cornea  in,  553 
tearing  out  capsule  in,  593 
technic,  503,  550,  606-622 
toilet  of  wound  after,  517,  575 
vacuum,  of  Hulen,  576 
vitreous  escape  in,  529,  574 
with  iridectomy,  547 
with    prcliminarv    iridectomy, 

549 
without  capsulotomy,  567 
without  iridectomy,  505 
Eye,  deviating,  159 

extraction  of  foreign  bodies  from 

interior  of,  687 
foreign  bodies  in,  687 
preparation  of,  502 
shades,  22-25 
shields,  22-25 
speculum,  107,  109 
squinting,  159 
Eyeball,  amputation  of,  436 
enucleation  of,  487 
accidents  in,  491,  493 
implantation  of  artificial  globe, 

4«5 
perforation  of  sclera  in,  491 
evisceration  of.      (See   Exentera- 
tion.) 
foreign  bodies  in,  687 

Rontgen  rays  in,  699-717 
massage  of,  46,  600,  637 
Mules'  operation  on,  435 
operations  on,  379 
steel  in,  687 
Eye-bath,  37 
Eye-cup,  37 

Eyelashes,  epilation  of,  209,  221 
Eyelids,  elephantiasis  of,  230 
coloboma  of,  302 
eversion  of,  207 
operations  upon,  207 
plastic    operations    on,     DiefTen- 

bach's,  296,  297 
ptosis  of,  230 
spasm  of,  253 
Eye-muscles,  operations  on,  158 


Failure  to  open  lens  capsule,  526 
Falchi's   operation    for   central    colo- 
boma of  upper  lid,  302! 
False    passage    in     i:)rolnng    lacrimo- 

nasal  duct,  124,  129 
Fergus'  operation  for  ptosis,  237 

trephining  of  sclera,  641 
Filtration  scar,  417,  477 
Fisher's  lid  retractor,  551 
Fistula  of  lacrimal  sac,  152 
Fixation  forceps,  86,  87 
Fixing  eye,  86,  91,  506,  551,  564-5,  596 
suture     in     Fuchs'     method     of 
tarsorrhaphy,  221 
Flap,  conjunctival,  508,  650 
Flaps,  pedicled,  305 
dressing,  316 
preparation  of,  314 
selection  of,  309 
Flarer's  operation  for  trichiasis,  280 
Fluoroscope  for  locating  foreign  bodies 

in  eyeball,  700 
Forceps,  86-107 

advancement,  95 
capsule,  94 
cilium,  95,  209 
dressing,  92 
entropion,  98-99 
fixing,  86--91 
Barr's  87 
Beard's,  87 
hemostatic,  99 
iris,  93,  467 
Knapp's  roller,  365 
Hd,  95 

mouse-tooth,  91 
needle,  103 
rat-tooth,  91 
rotary,  94 
trachoma,  95 
toilet,  94 
Forceps-scissors,  85 
Foreign  bodies  in  anterior  chamber, 
686 
in  cornea,  379-383 
in  eyeball,  687 
in  iris,  689 
in  lens,  690 
in  orbit,  670 

in  posterior  chamber,  69 1 
in  vitreous,  692 

loosening  with  magnet,  725 
drawing  into  anterior  chamber, 
724 
Rontgen  rays  for,  699-719 
Forster's    method    of    ripening    cata- 
ract, 597 
Fox's  operation  of  peridectomy,  361 
Francis'    method    of    closing    scleral 

wounds,  428 
French     method     of    blepharoplasty, 

296 
Frohlich's  trephination  of  sclera,  426 


736 


Fricke's    method    of    blepharoplasty, 

306 
Frost-Lang  operation  of  implantation, 

485 
Fuchs'  lattice  bandage,  24 

tarsorrhaphy,  221 
Fukala's  suture  for  ectropion,  285 


Gaillard's  suture  for  entropion,  255 
Galezowski's  operation  for  pterygium, 

,  355 

for  ptosis,  241 
crucial  anterior  sclerotomy,  419 
excision  of  retro-tarsal  folds,  370 
Galvano-cautery.  (See   Actual 

CsLUtery.) 
Galvano-puncture  for  conical  cornea, 
396 
for  detachment,  427 
for  paracentesis,  394 
Gama  Pinto's  operation,  593 
Gaping  of  wound  in  cataract  extrac- 
tion, 533 
Gauze,  13 

Gayet's  operation  for  entropion,  261 
iridectomy,  466 
iridotomy,  441 
General     anesthesia     in     ophthalmic 

operations,  12 
Giant  magnet,  technic  for,  721 
Giflord  on  recurrent  pterygium,  359 

late  healing  after  extraction,  543 
Gifford's  evisceration,  432 
Gland,  extirpation  of  orbital  lacrimal, 
156 
palpebral  lacrimal,  153 
Glass  ball  in  e3^e,  introduction  of,  435 
Glass  in  the  eyeball,  687,  691 
Glasses,  protective,  25 
Glaucoma,    absolute,     anterior    scle- 
rotomy for  417,  624,  626 
posterior  sclerotomy  for,  420 
acute,  iridectomy  for,  454 
after    cataract    operations,     544, 

566,  589 
arrachement  of  iris  in,  470 
choice  of  measures  for,  658 
chronic,  434,  623 
coloboma  in  iridectomy  for,  469 
cyclodialysis  in,  422 
filtration  scar  in,  417,  477 
paracentesis  for,  389 
hemorrhage,    expulsive   after  iri- 
dectomy for,  473 
incision  for,  457,  471 
iridectomy  in,  454,  624 

technic  of,  457-470 
massage  of  eyeball  in,  393 
newer  operations  for,  623 
posterior  sclerotomy  for,  420 
relapsing,  418,  420 
review  of  operations  for,  656 


Glaucoma,  scleral  puncture  in,  420 

scleriritomy  for,  418 

clerotomy  for,  417,  420,  624 

secondary,  544,  566 

simple,  623 

tardy  closure  of  wound  in  opera- 
tions for,  477 

wounding  lens  in  iridectomy  for, 
475 
Globe.      (See  Eyeball.) 
Gloves,  operating,  2 
Goggles,  27 

Golovine's  operation  for  conical  cor- 
nea, 398 
Graefe.      (See  von  Graefe.) 
Gradenigo's  intracapsular  extraction, 

569 

Grafting,  corneal,  409-413 

Durr's,  409 

Magitot's,  412 

Von  Hippel's,  411 

Zirm's,  412 
Grafts,    cutaneous,    in    operation    for 

ectropion,  319,  337 
Grandemont's    operation    for    ptosis, 

241 
Granules,  trachoma,  expression  of,  365 
Grattage,  364 

Green's  operation  for  entropion,  275 
Gruening's  operation  for  ptosis,  241 
Grunert's  operation  for  conical  cornea, 

397 
Guilloz  localization  methods,  71 1-7 17 
Gutta  percha  film,  21 


H 


Haab's  large  magnet,  695 

Hansel-Sweet,  enucleation,  484 

Harlan's  operation  for  svmblepharon, 
336 
blepharoplasty,  301 

Hasner's    blepharoplastic    operation, 
308 

Heat,  42 

Heine's  cyclodialysis,  422,  651 

Heisrath's  tarsectomy,  370 

Helmbold's   operation   for   ectropion, 
287 

Hemorrhage    in    enucleation    of   eye- 
ball, 493 
expulsive,    after    iridectoni}^    for 
glaucoma,  473 
in  cataract  extraction,  513 

Hemostasis    in    lacrimal    operations, 

151 

Herbert's  sclerotomy,  628-631 
Hess's  operation  for  ptosis,  233 
Heurteloup's  artificial  leech,  53 
Hirschberg's  electromagnet,  695 
History  of  extraction,  600-615 
Holocain,  lo-ii 
Hook,  blunt,  67,  468 
sharp,  66-67,  468 


INDEX 


737 


Hook,  squint,  67-71 

its  many  uses,  71 
Hooks,   Beard's,   for  closing  \YOunds, 

382 
Hordeolum,  incision  of,  213 
Hotz  operation,  260 

method  of  skin  grafting,  325 
Hotz-Anagnostakis  operation  for  en- 
tropion, 260 
Hotz  operation  for  ectropion,  325 

symblepharon,  339 
Hulen's  vacuum  extraction,  576 
Hunt-Tansley    operation    for    ptosis, 

236 
Hydrochlorate  of  cocain,  10 
Hvdrophthalmos,  419,  453-455 
Hyphema,  390,  477,  525,  546 
Hypopyon,  390 
keratitis,  390 


Illumination  for  operations,  8-10 
Implantation  of  artificial  globe,  485 
silk  thread  for  glaucoma,  654 
vitreous,  435 
Incision  of  anterior  lens  capsule,  509, 
526,  554-7 
wall  of  lacrimal  sac,  134 
in      anterior      sclerotomy       (De 

Wecker's),  417 
in  cyclodialysis  (Heine's),  422 
for   extirpation   of    lacrimal   sac, 

H4      . 
in    extraction    of    cararact,    507, 
524,  552,  606-622 

Earth's,  607 

Beer's,  607 

Bowman's,  608 

Critchett's,  582 

Daviel's,  606 

De  Wecker's,  612 

De  Wenzel's,  606 

Jacobson's,  611 

Jaeger's,  614 

Kiichler's,  613 

Lebrun's,  614 

Liebreich's,  614 

Pamard's,  580 

Pellucci's,  607 

Richter's,  606 

Santerelli's,  607 

Travers',  608 

Von  Graefe's,  608-612]  ] 

Weber's,  613 
in  iridectomy  for  glaucoma,  454 
for  iridotomy,  441 
with    lancet    in    iridectomy    for 

glaucoma,  454 
in  optical  iridectomy,  449 
in  paracentesis  cornea,  389 
in  posterior  sclerotomy,  420 
in   simple   extraction,    507,    524, 
552,  606-622 
Incisions  of  the  orbit,  681 
47 


Indian  method  of  blejiharoplasty,  305 

operation  for  cataract,  570 
Infection    of    cornea    following  cata- 
ract extraction,  540 
Infiltration  anesthesia,  il 
Inhalers,  12 
Injections,  hypodermic,  47 

intracapsular,  58,  599 

subconjunctival,  47 

paraffin,  140,  141 

tissue,  46 
Injectors,  paraffin,  141 
Injuries  of  lens  during  iridectomy  for 

glaucoma,  475 
Ink,  India,  in  tattooing,  414 
Insanity    after    cataract  :  extraction, 

545 
Inspection  of  eye,  after  extraction,  518 

for  contained  foreign  body,  698 
Instillations,  35 

Instruments,  boxes  for,  114-116 
care  of,  114-118 
management  of,  53,  119 
manipulation  of,  110-116 
testing  edges  and  points  of,  1 1 8- 

119 
preparation  of,  2,  4,  11 6-1 17 
sterilization  of.  2,  116 
Interior  of  eye,  extraction  of  foreign 

bodies  from,  687 
Intermarginal  incision,  266 
Internal  tarsorrhaphy,  222 
Intracapsular  extraction,  567 
Beer's,  567 
Christensen's,  568 
Delgado's,  569 
Gradenigo's,  569 
Hulen's,  576 
Pagenstecher's,  568 
Richter's,  568 
Roosa's,  568 
Sharp's,  568 
Smith's,  570 
injections,  599 
prothesis,  485 
Intratenonian  injections,  58 

prothesis,  485 
Introduction  of  glass  or  gold  balls  into 

the  eye,  435 
Iridectomy,  447 

accidents  in,  471-477 
anesthesia  in,  456 
antiphlogistic,  453 
blood  in  anterior  chamber,  477 
cataract  following,  475 
choice  of  knife  for,  462 
coloboma  in,  468 

"key-hole,"  469 
complications  following,  471-477 
consecutive  accidents,  477 
expulsive  hemorrhage,  473 
general  considerations,  455 
Graefe  knife  in,  465 
grasping  the  iris,  467 
historical,  447 


738 


Iridectomy    in    cataract    extraction, 
547,  550 
in  glaucoma,  454 
incision  for,  457,  471 
in  hemorrhagic  glaucoma,  454 
in  hydrophthalmus,  419,  453-455 
in  magnet  operations,  687 
intraocular  hemorrhage  after,  473 

477 
in  zonular  cataract,  450 
kind  of  knife  for,  462,  466 
Kuhnt's  forceps  in,  468 
Liebreich's  forceps  in,  467 
modifications  of,  462 
Burnett's,  466 
Carter's,  466 
Dianoux's,  466 
Gayet's,  466 
mydriatics  and  myotics  in,  455 
optic,  449 

Pope's,  451 
point  of  entrance   of   keratome, 

457 
position  of  new  pupil,  449 
preliminary,   in  cataract  extrac- 
tion, 449 
preparatory,  449 
prolapse  of  vitreous  in,  475,  476 
pupillary  bridge  in,  431,  454,  474 
size  and  shape  of  coloboma,  468 
technic  of,  457 
therapeutic,  453-455 
toilet  of  eye  after,  461 
value  of,  in  extraction,  547 
varieties  of,  and  indications,  448 
withdrawing  the  iris  in,  467 
Iridencleisis,  451 
Iridesis,  449,  451 

Iridochoroiditis,     suppurative,      enu- 
cleation in,  495 
Iridocyclitis  after  cataract  extraction, 

539 
Iridodesis,  451 
Iridodialysis,  474 
Iridolysis,  444 
Iridorrhexis,  448 
Iridotomy,  437 

De  Wecker's,  438 
Gayet's,  441 

in  secondary  cataract,  589 
modifications  of,  440 
technic  of,  438 
Iris,  arrachement  of,  470 
bombe,  453 

bridge  coloboma  of,  451,  474 
coloboma  of,  468-471 
excision  of,  447,  574 
forceps,  93,  467 
foreign  bodies  in,  687 
hooks,  67,  68,  468 
implantation  cyst  of,  after  cyclo- 
dialysis, 425 
operations  on,  437 
prolapse    of,    after    cataract    ex- 
traction, 531,  534,  538 


Iris,   prolapse   of,    treatment  of,  531, 

534. 
reposition  of,  531 
scissors,  85 
spatula,  71 
Iritis  after  cataract  extraction,  539 
iridectomy  in,  453-455 
in  chronic,  453-455 
in  recurrent,  453-455 
operative  treatment,  of  453-455 
Irito-ectomy,  438,  439 

Abadie's,  442 
Irito-ectomy,  Agnew's,  442 

modifications  of,  442 
Irito-dialysis,  438,  439,  440 
Iritomy,  437 
Irrigation,  38 

of    anterior    chamber    after    ex- 
traction, 514,  557 
Irrigators,  36,  514 


J 


Jackson's  tendon  displacement,  199 
Jacobson's  extraction,  611 
Jager's  cataract  knives,  614 
incision,  614 
lid  forceps,  99 
spatula,  109 
operation  for  ectropion,  298 
Jasche-Arlt   operation   for    trichiasis, 

259 
Jones  (Wharton-)  operation  for  ectro- 
pion, 297 


K 


Kalt's,  corneal  suture,  553 

Keratitis    after    cataract    operation, 

544 

striped,  544 
Keratoconus,  operations  for,  395-400 
Keratoglobus.         (See    Hydrophthal- 
mus.) 
Keratome,  62,  559 
Keratonyxis,  582,  585 
Keratoplasty,  404 

by  conjunctival  flaps,  404-408 

partial,  404 

total,  404 
Key-hole  coloboma,  469 
Knapp's  blepharoplasty,  302 

knife  needle,  65 

lid  clamp,  95 

method  for  staphjdoma,  401 

needle  forceps,  103 

operation  for  pterygium,  351 
for  squint,  186 
for  symblepharon,  332 

peripheral  capsulotomy,  557 

rhinorraphy,  226 

trachoma  forceps,  365 
Knies'  irido-sclerotomy,  419 


INDEX 


739 


Knife,  cataract,  forms  of,  62,  606-610 

discission,  559,  561 

Graefe,  62,  610 

lacrimal,  61 

needle,  Knapp's,  65 

needles,  65 
Kronlein's  operation,  672-678 

indications  for,  677 

modifications  of,  676 
Kuchler's  incision  for  anterior  staph- 
yloma, 613 

for  cataract,  613 
Kuhnt's     conjunctival     keratoplasty, 
405-408 

expression  methods,  365 

operations  for  trachoma,  370 
Kuhnt-Mtiller    operation    for    ectro- 
pion, 287 
Kyanopsia,  547 


Lacrimal  canal,  hemostasis  of,  151 
operations  on,  120 
slitting  of,  131 
threading,  126 
dilator,  Landolt's,  120 
electrolysis,  137 
glands,  excision  of,  156 
extirpation  of  orbital,  153 
of  palpebral,  157 
knife,  61 
probes,  121 

Bowman's,  121 
introduction  of,  123-126 
Weber's,  109 
Theobald's,  121 
probing,  123-126 
punctum,  dilating,  120 

sealing,  136 
sac,  excision  of,  138 
extirpation  of,  138-149 
fistula  of,  133 
incision  of,  134 
obliteration  of,  152 
sounds,  Beard's,  122 

Weber's,  109 
stenosis  of  infants,  129 
stricture,  incision  of,  133 
syringe,  Wilder-Beard,  126 
syringing,  126 
Lacrimonasal    stenosis    in    new-born, 

129 
Lagrange's    implantation    of    rabbit's 
eye  in  Tenon's  capsule,  487 
sclerectomy,  637 
Lance  keratomes,  62 
Landolt's  lacrimal  dilator,  120 

operation  for  restoration   of  lid, 

309 
method  of  advancement,  171 
tendon  lengthening,  197 
Langier-Arlt     method     for     symble- 
pharon,  333 


Lang's   operation    for   dividing   syne- 
chia, 444 
Latent  squint,  159 
Lavage  after  extraction,  514,  557 
Lebrun's  method  for  ectropion,  614 
Leeches,  51 

natural,  51 
artificial,  51 
Le  Fort-Wolfe  transplantation  opera- 
tion for  entropion,  313,  319 
Leiter's  tubes,  44 

coils,  44 
Lens,  foreign  bodies  in,  691 

removal  of.     (See  Extraction.) 
Leukoma    of    cornea,    tattooage    for, 
414 
trephining  for,  395 
Levator,  shortening  of  for  ptosis,  238 
Lid  clamps,  95 

Desmarrcs',  99 
Knapp's,  95 
elevator,  74 
eversion  of,  207 
forceps,  95 
operations  upon,  207 
Liebreich's  method  of  extraction,  614 
Ligation  of  canaliculi,  136 

of  pterygium,  355 
Linear  extraction  of  cataracts,  559 
Local  anesthesia  in  ophthalmic  opera- 
tions, 10 
Localization  of  foreign  bodies  in  eye, 
697-719 
Davidson's  method,  712 
geometric,  710 
Guilloz's  method,  713 
Sweet's  method,  702 
comparison  of  methods  of,  719 
control  of  the  eye  in,  716 
stereoscopic,  701 
Localizer,  Sweet's  new,  706 
Loops,  wire,  73,  74 


M 


Magitot's  method  of  corneal  grafting, 

412 
Magnet  of  Haab,  695 
of  Hirschberg,  695 
relative  merits  of  small  and  large, 

726 
operations,  694 

causes  of  insuccess  in,  727 
history  of,  694 
technic  of,  694,  719 
small,  in  foreign  bodies    in    eye- 
ball, 695 
Manipulation  of  instruments,  i  lo-i  14 
Masks,  operating,  6-8 

protective,  23 
Massage,  46,  600,  637 

of  cornea  after  paracentesis,  393, 
637 


740 


INDEX 


Massage  of  eyeball,  46,  393,  637 
in  embolism,  393 
in  glaucoma,  93,  600,  637 
in  trachoma,  364 
vibratory,  48 
Mayou's  implantation  of  silk  thread 

for  glaucoma,  654 
McKeown's  irrigator,  495 
McRejmold's  operation  for  pterygium, 

353 
Median  tarsorrhaphy,  222 
Meibomian  cyst  (see  also  Chalazion), 

213-220 
Meisner's  restoration  of  lower  lid,  318 
Mellinger's  speculum,  107 
Membrane,    Descemet's,    detachment 

of,  in  cyclodialysis,  425 
Mercury  cyanid  injections,  48 
Metallic  foreign  bodies,   removal   of, 

687 
Meyer's  method  of  enucleation,  483 
Mooren's  iridectomy,  449 
Motais'  method  of  advancement,  177 
operation  for  ptosis,  242-3,  247- 
250 
Mueller's  myectomy,  190 

sclerectomy,  427 
Mules'  operation  for  artificial  vitreous, 

435 
ptosis,  233 
repositor,  108 
Miiller-Kuhnt    operation    for    ectro- 
pion, 287 
Mydriasis  in  extraction,  502,  534 

in  iridectomy,  455 
Myectomy,  190 


N 


Narcosis,  11 

Needle  knife,  Knapp's,  65 

stop,  Bowman's,  65 

sewing,  109 

tattooage,  67,  414-5 
Nerve,    optic,    resection    of,    in    enu- 
cleation, 470 
New-born  children,  probing  in,  132 
Nicati's    operation    of    anterior    scle- 
rotomy, 418 
Nitrate  of  silver,  44 
Noyes'  shortening  operation,  189 
Nuel's  suture  for  scleral  wound,  430 


Oblique  illumination  for  foreign  body 

in  cornea,  371 
Obliteration  of  lacrimal  sac,  152 
Ocular  mask,  Ring's,  24 

muscles,  operation  upon,  158 
Ointments,  39 
Oliver's  restoration  of  cul-de-sac,  340 


Operating  room,  8 
gloves,  2 
masks,  6-8 
Ophthalmoscope  for  locating  foreign 
body  in  eyeball,  697 
its  value   in   the  surgery  of   de- 
tachment, 668 
Optic    nerve,    resection    of,    in    enu- 
cleation, 489 
Orbit,  cellulitis  of,  681 
cysts  of,  679 
exenteration  of,  683 
partial,  685 
total,  684 
exostoses  of,  operations  for,  680 
foreign  bodies  in,  670 
diagnosis  of,  670 
technic  of  removal,  671 
hemorrhage  in,  685 
incisions  of,  681 

Kronlein's  operation  upon,  672- 
678 
indications  for  ,677 
modifications  of,  676 
operations  upon,  670 
tumors  of,  678 

technic  of  removal,  680 
Ouletomy  of  Panas,  418 


Pagenstecher's   intracapsular    extrac- 
tion, 568 

knife-needle,  65 

operation  for  entropion,  263 
ptosis,  232 
Panas'   operation  for  artificial  pupil, 
430 

for  anterior  sclerotomy,  418 

for  entropion,  263 
lower  lid,  279 

for  ptosis,  235 

for  restoration  of  lid,  309 

for  symblepharon,  336 
Pannus,  operations  for,  377 
Panophthalmitis,  enucleation  in,  495 
Paracentesis  of  cornea,  389 

in  conical  cornea,  391 

in  embolism  and  thrombosis,  391 

in  hyphema,  390 

in  iritis  and  iridocyclitis,  390 

in  ulceration  of  cornea,  390 
Paraffin  in  Tenon's  capsule,  467 

for  artificial  vitreous,  435 

injection  of,  into  lacrimal  sac,  139 
Parinaud's  operation  for  ptosis,  241 
Patches,  22 

Patient,  preparation  of,  4-6 
Paul  of  Egina,  method  for  entropion 

^>y,  259 

Pedicelcd  fiaps  in  plastic  operations, 
305 
dressing  for,  316 
preparation  of,  314 
selection  of,  309 


INDEX 


741 


Perforation  of  sclera  in  tenotomy  for 

squint,  166 
Peridectomy,  360 
Peritomy,  360 

Agnew's  method  of,  360-1 
Phlebotomy,  49 

Pince-ciseaux  of  De  Wecker,  85 
Pope's  optic  iridectomy,  451 
Posterior  chamber,  foreign  bodies  in, 
691 

discission,  593 

sclerotomy   for   removal    of   for- 
eign bodies,  721 
indications  for,  422 
in  glaucoma,  422 
Masselon's  method,  419 
modifications  of,  419 
technic  of,  419 
Post-choroidal  hemorrhage,  532,  576 
Postoperative  astigmatism,  576 

dementia,  545 
Precorneal  iridotomy,  439 
Preliminary  iridectomy,  449 
Preparation  of  hands,  2 

of  instruments,  2-4 

of  patient,  4-6 
Preparatory  iridectomy,  449 
Pressure  bandage,  14 
Priestly  Smith's  balance    for    testing 

knives,  119 
Prince's  method  of  advancement,  174 

advancement  forceps,  95 
Primrose's  operation  for  pannus,  377 
Probe,  lacrimal,  121-123 

Beard's,  122 

Bowman's,  121 

introduction  of,  123-126 

Theobald's,  121 
Prolapse  of  iris,  531,  534,  538 

of  vitreous,  539,  574 
Protective  glasses,  25 

masks,  23 

shields,  23 
Provisional  tarsorrhaphy,  312 
Pterygium,  345 

Arlt's  excision  for,  347-8 

causes  of  failure,  358 

cautery  of,  356 

Desmarres'    transplantation    for, 
,      350,  355 

electrolysis  of,  356 

excision  with  conjunctivo-plasty, 

,,     349 

false,  357 

Galezowski's  operation  for,  355 

historical,  347 

Knapp's  operation  for,  351 

ligation  of,  355 

McReynold's  operation  for,  353 

recurrent,  357 

GiflFord  on,  359 

transplantation,  350 

Ptosis,  or  blepharoptosis,  230 

Angelucci's  method,  240 

Beard's  method,  244 


Ptosis,  Bishop's  method,  234 

Bowman's  method,  240 

choice  of  method  for,  250 

Darier's  method,  231 

De  Grandemont's  method,  241 

Denonvillier's  method,  231 

De  Wecker's  method,  232 

Dransart's  method,  232 

Eversbusch's  method,  238 

Fergus'  method,  237 

Galezowski's  method,  241 

Gosselin's  method,  231 

Graefe's  method,  231 

Gruening's  method,  241 

Hess'  method,  233 

historical,  320-231 

Hunt's  method,  231 

Hunt-Tansley  method,  236 

Morand's  metliod,  231 

Motais'  method,  242-3,  247-250 

Mules'  method,  233 

Pagenstecher's  method,  232 

Panas'  method,  235 

Parinaud's  method,  241 

principles  involved,  231 

Snellen's  method,  239 

summary,  246 

Vautrin's  method,  231 

varieties  of,  230 

Wilder's  method,  234 
Puncta  lacrimalia,  sealing  of,  136 

stenosis  of,  in  infants,  129 
Punction    of    sclera.      (See    Posterior 

sclerotomy.) 
Puncture    of    cornea.     (See  Paracen- 
tesis.) 
Pupil  in  cataract  extraction,  498 

position  of  artificial,  449 

rigidity  of,  in  extraction,  527 
Pupihary  bridge,  451,  474 


Rabbit's     conjunctiva,     transplanta- 
tion of,  334 
cornea,  transplantation  of,  409 
eye,  transplantation  of,  487 
Raclage  for  trachoma,  364 
Radiography     for     locating     foreign 
bodies  in  eyeball,  697-719 
positions  of  head  and  tube,  7 1 7 
Rays,  Rontgen,  in  foreign  bodies  in 

eyeball,  699-719 
Recession,  tendon,  192 

of  Prince,  199 
Reclination  for  cataract,  579 
Red  vision  after  extraction,  520 
Redressing  the  eye,  27,  518-520 
Removal    of    cortical    substance    in 
extraction     without     iridec- 
tomy, 512 
of  sutures,  30 
Resection  of  tarsus  for  ptosis,  241 
trachoma,  370 


742 


INDEX 


Restoration  of  cul-de-sacs,  339-345 
of  lower  lid,  318 
Buedinger's,  318 
Meisner's,  318 
Retraction  of  caruncle  following  ten- 
otomy, 166 
Retractors,  lid,  74,  551 

wound, 146 
Rhinorraphy,  226 
Richet's  operation  for  restitution   of 

commissure,  308 
Ring's  ocular  mask,  23 
Rogman's  method  for  epicanthus,  227 
Rontgen     rays     in     locating    foreign 

bodies,  699-719 
Roosa's  extraction  in  capsule,  568 


Sac,  excision  of  lacrimal,  138 

extirpation  of  lacrimal,  138 
Saemisch's  incision,  392 
Samelsohn's      method     for     symble- 

pharon,  337 
Savage's  method  for  shortening  ten- 
dons, 187 
Scalpels,  59 

Schweigger's  resection  for  squint,  190 
Scissors,  75 

canthotomy,  81 

capsule,  Charrierre's,  86 

Dowell,  86 

enucleation,  81 

forceps  of  De  Wecker,  85 

general,  75 

iris,  85 

manipulation  of,  176 

strabismus,  77 

Stevens'  tj,  181 

Terson's,  81 

Warlomont's  hemostatic,  490 
Sclera,  exenteration  of,  430 

operations  on,  417 

perforation  of,  in  enucleation,  491 
in  tenotomy,  166 

sutures  of,  428 

trephination  of,  426,  641 

wounds,  428-430 
Scleral  incision  for  magnet  operation, 
718 

puncture,  661 

sutures,  428 
Sclerectomy,  426,  624 

Bettremieux's,  652 

for  detached  retina,  427 

for  magnet  operations,  720 

grill-like  of  Wicherkiewicz,  632 

Holth's,  640 

Lagrange's,  638 

L.  Muller's  method,  427 
Scleriritomy,  418 
Sclero-corneal  trepliination,  641 
Scleroticopuncture,  582 
Sclerotomy,  anterior,  417,  624,  626 

Beard's,  635 


Sclerotomy,  Bjerrum's,  631 
De  Wecker 's,  417 

combined,  419,  627 
equatorial,  625 
for  retinal  detachment,  427 
Galezowski's  crucial,  419 
Herbert's,  628-631 
indications  for,  419 
in  glaucoma,  417,  420,  624 
in  hydrophthalmus,  419 
posterior,  20 

in  detachment,  625 
indications  for,  422 
in  glaucoma,  422 
Sealing  the  lacrimal  puncta,  136 
Secondary    cataract     (see  After-cata- 
ract), 563 
squint,  166,  200 
Section,     Saemisch's     in     serpiginous 

ulcer,  392 
Senile  cataract.     (See  Extraction.) 
Serpiginous  ulcer  of  cornea,  Saemisch 
section  in,  392 
thermocautery  in,  392 
Severance  of  optic  nerve  in  enuclea- 
tion, 489 
Shades,  24 
Shields,  23 
Shortening  of  lid  for  senile  ectropion, 

281 
Shrunken  lens  in  children,  operation 

for,  560 
Sideroscope,  698 

in  foreign  bodies  in  eyeball,  699 
Simple  extraction,  505 
Skin-grafts  in  operations  for  cicatricial 

ectropion,  319,  337 
Skin  grafting,  319 

Thiersch's  method,  324 
Wolf-Le  Forte  method,  313,  319 
without  pedicle,  312 
Slitting  up  of  the  canaliculus,  131 
Small   magnet    in   foreign   bodies    in 

eyeball,  695 
Smith's    methods    of     extraction     in 
capsule,  571 
accidents  and  complications,  574 
Snellen's  operations  for  ptosis,  239 
suture  for  ectropion,  282 
for  entropion,  255,  262 
tenotomy,  162 
wire  loop,  74 
Sounds,  lacrimal,  122 
Spastic  ectropion,  operation  for,  280 
Snellen's  suture  for,  282 
after  extraction,  546 
operation  for,  253 
Spatula,  iris,  71 

lid,  Jaeger's,  109 

knife.  Beard's,  73 

Si)eculum,  eye,  107-9 

lid,  107 
Spencer- Watson's    operation    for    en- 
tropion, 261 
Sphincterectomy,  452 


743 


Sphincerolysis,  444 
Splitting  of  cornea,  471,  594 
Sponges,  31 
Spoons,  72 
metal,  72 

Pagenstecher's,  568 
Spratt    on    intratcnonian    implanta- 
tion, 486 
Spud,  foreign  body,  70,  380 
Squint  (see  also  Strabismus),  158 

advancement  for,    169-185,  201- 

206 
hooks,  67,  71 
operations  for,  160 
secondary,  161,  200 
tenotomy  for,  160 

Von  Graefe's,  161 
varieties  of,  158 
Staphyloma,  anterior,  operations,  for, 
400 
of  cornea,  400 
partial,  403 
total,  401 
pellucidum,  operations  for,  395 
Staub  on  synechiotom}',  444 
Stellwag's  suture,  256 
Stenosis  of  lacrimal  canal  of  infants, 
129 
punctum,  120 
Stephenson's      tendon      lengthening, 

195-6 
Stereoscopic    localization    of    foreign 

bodies  in  eyeball,   701 
Sterilization  of  dressings,  6 

instruments,  2-4 
Stevens'    tenotomy    instruments,    "]"], 

163,  181 
Stop  needle.  Bowman's,  65 
Strabismus,  158 

advancement  for,   169-185,  201- 

206 
hooks,  67 
kinds  of,  158 
operations  for,  160 
scissors,  177 
secondary,  166,  200 
tenotomy  for,  160 
Streatfield's  tarsoplasty,  262 
Strabotomy,  160 

Stricture,  incision  for  lacrimal,  133 
Stricturotome,  Stilling's,  133 
Subconjunctival  injections,  47,  542 
Subcutaneous     injection     of     cocain, 

II,  12 
Subtenonian    injection     of     mercuric 

cyanid,  48,  542 
Suture,  control,  curb  and  restrain,  in 
tenotomy,  193 
corneal,  534 
Sutures  for  ectropion,  282 

for  entropion,  255 
Swabs,  32 
Swelling  of  lens,  corneal  puncture  in, 

566,  589 
Sweet-Hansel  enucleation,  484 


Sweet's    Rontgen    ray    methods    for 
locating  foreign  bodies,  702- 
713 
Symblepharon,  329,  330 
anterius,  329 

operations  for,  method  by  mucous 

or  cutaneous  grafts,  334-337 

pcdicklcd  flaps  of  conjunctiva 

or  skin,  332-336 
sliding   flaps   of    conjunctiva, 
332 
posterius,  329,  330 
totalis,  329,  333 
Sympathetic  inflammation  after  cata- 
ract, 611 
enucleation,  485 
exenteration,  485 
Frost's  operation,  484 
Syndcetomy,  360 
Synechia,  anterior,  443-447 

Agnew's  method  for,  446 
Beard's,  445 
Staub's,  444 
posterior  (corelysis),  443 
Synechiotomy,  443 
Wenzel's,  443 
Syringe,  Anel's,  127 
Syringing  lacrimal  canal,  126-129 
Szymanowski's    operation    for    ectro- 
pion, 290,  301 
blepharoplasty,  301 


Tagliacotian    method    of    autoplasty, 

326-7 
Tansley-Hunt    operation    for    ptosis, 
236 

canula  for  Anel's  syringe,  127 
Tarsectomy,  370 
Tarso-chiloplastic  operation,  262 
Tarsorrhaphy,  221 

Arlt's  internal,  222 

external,  221 

Fuchs'  method,  221 

median,  223 

provisional,  312 
Tarsus,    excision    of,    Kuhnt's    com- 
bined, 370-377 
isolated,  374 

extirpation,  370 

for  ptosis,  231,  241 

simple,  371 
Tatooing,  influence  on  vision,  413,  416 

De  Wecker's,  413 

needle,  67 

of  cornea,  413 

operation  of,  414 

remarks  on,  416 
Taylor's   method   for   symblepharon, 

336 
Teale's  operation   for    symblepharon, 

332 
Tear  sac  speculum,  146 


744 


INDEX 


Tearing  of  iris  in  iridectomy,  470 
Tendon  advancement,  169-185,  201- 
206 

displacement,  199 

lengthening,  195 

recession,  192 

resection,  189 

shortening,  187,  189-192 

tucking,  187 
Tenon's  capsule,  advancement  of,  185 

artificial  globe  in,  after  enuclea- 
tion, 485 
Tenotomy,  160-169 

Beard's,  163 

complete,  168,  169 

complications  after,  165 

Critchett's,  162 

dosing  the  effect  of,  168 

graduated,  168,  198 

of  vertical  recti  for  lateral  devia- 
tions, 198 

open,  168 

partial,  18,  198-9 

Snellen's,  162 

subconjunctival,  168 

Von  Graefe's,  i6i 
Terson's  operation  for  ectropion,  291 

scissors,  81 
Therapeutic  iridectomy,  453-455 
Thermocautery  in  serpiginous  ulcers, 
392 

in  detachment  of  the  retina,  662 
Thiersch's  skin-grafting  method,  324 

graft,  324 
Thread  operation,   subcutaneous,  for 
ptosis,  232 

for  lacrimal  obstruction,  126 

Graefe's,  169 
Tillaux  method  of  enucleation,  483 
Tobacco-pouch  suture,  431,  541 
Todd's  tendon  tucker,  188 
Toilet  of  wound  after  extraction,  517, 
575 

after  iridectomy,  461 
Toti's  operation,  149 
Trachoma,  cautery  for,  368 

chemical  treatment  of,  368 

classification  of  methods,  363 

combined  excision  for,  371 

curettage  for,  369 

excision  for,  369-370 

expression  of  follicles  in,  365 

forceps,  Knapp's,  365 
Kuhnt's,  366 
Whitney's,  366 

granules,  expression  for,  365 

grattage  in,  364 

isolated  excision  for,  374 

massage  for,  364 

meclianical  treatment  of,  363 

operations  for,  363,  369 

radiation  for,  369 

siinijje  excision  for,  370 
Transplantation,  corneal,  409,  413 

for  pterygium,  350,  355 


Transplantation  of  rabbit's  conjunc- 
tiva, 334 
eye,  487 
operations,     double,     for     ptery- 
gium, 351 
Trepanation  of  sclera,  641 
Trephine,  Beard's,  647 
Bowman's,  641 
Elliot's,  642 
Pusey's,  642 
Stephenson's,  642 
Verhoeff's,  647 
Von  Hippel's,  411 
Trephining  of  cornea,  411 
of  sclera,  426,  641 
Frohlich's,  426 
of  sclero-cornea,   of    Elliot,   642- 
646 
Trichiasis,  259,  273 

double  transplantation  for,  273 
electrolysis  for,  212 
operations  for,  259,  273 
Flarer's,  280 
Hotz-Anagnostakis,  260 
Jasche-Arlt,  259 
Panas',  263 
Spencer-Watson,  261 
Tripier's  operation  for  ectropion  from 

bone  lesions  of  orbit,  317 
Trousseau's  folding  operation,  188 

extraction,  555 
Tucking  operations  for  squint,  187 


Urine  in  cataract,  497 


Vacuum  extraction,  576 
Van  Lint's  sclerotomy,  634 
Van  Milligen's  tarsochiloplasty,  262 
Venesection,  49 

Verhoeff's     advancement     operation, 
175 
lengthening  operation,  197 
suture     and     button     operation, 

283 
trephine,  647 
Vibration  massage,  46 
Vicenti's  anterior  sclerotomy,  418 
Vienna  enucleation  operation,  479 
Vitreous,  foreign  bodies  in,  extraction 
of,  692 
prolapse   of,   in   extraction,    529, 
574 
during  discission,  584,  588 
in    iridectomy    for    glaucoma, 

475,  476 
sequela;  of,  529,  574 
Von  Amnion's  operation  for  ectropion, 
286,  296 


INDEX 


745 


Von  Arlt's  enucleation,  459 

incision  for  extraction,  615 
■    internal  tarsorrhaphy,  222 
operation  for  pterygium,  347 

for  symblepharon,  331 
rhinorraphy,  227 
scalpel,  59 
suture,  255 
tenotomy,  162 
Von    Graefe's    ectropion,    lower    lid, 
297 
entropion,  lower  lid,  279 
exenteration,  431 
extraction,  608-612 
Faden-opcration,  169 
iridectomy    for    glaucoma,    448, 

457 
knife,  62,  610 

in  iridectomy,  448,  457 
operation  for  ptosis,  231 
for  senile  entropion,  279 
for  spastic  entropion,  256 
tenotomy,  161 
Von  Hippie's  corneal  transplantation, 
410,  411 
trephine,  411 


W 

Waldhauer's  operation  for  entropion, 

262 
Walker's  lid  everter,  373 
Walther's  operation  for  ectropion,  287 

of  tarsorrhaphy,  222 
Warlomont's  lid  clamp,  99 

enucleation  scissors,  490 
Weber's  advancement,  173 

canaliculus  knife,  61 

cataract  knife,  613 


Weber's  incision  for  extraction,  613 

wire  loop,  74 
Wecker.     (See  De  Weaker.) 
Weeks'    operation   for   total    symble- 
pharon, 342 
Wenzel.     (See  De  Wenzel.) 
Wharton-Jones   operation    for   ectro- 
pion, 297 
Wicherkiewicz  method  for  epicanthus, 
228 

implantation  operations,  487,  488 

sclerotomy,  632 
Wilder's  chalazion  clamp,  99 

double  knife,  266 

operation  for  ptosis,  234 

paraffined  plates,  343,  344 
Wire  loop,  73 

Snellen's,  74 

Weber's,  74 
Withdrawing  iris  in  iridectomy,  467 
Wolfe  graft  in  ectropion,  313,  319 
►■  **    preparation  of,  321 
Woodruff's  operation  for  total  symble- 
pharon, 340 
Worth's  method  of  advancement,  176 
Wound,  gaping  of,  in  cataract  extrac- 
tion, 533 
Wound  of  lens  capsule,  in  excision  of 
iris,  475 

scleral,  treatment  of,  428-430 


X-rays  for  locating  foreign  bodies  in 
the  eyeball,  699-719 

Z 

Zirm's  keratoplasty,  412 
Zonule,  rupture  of,  475 
Zorab's  implantation  of   silk    thread 
for  glaucoma,  654 


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